Tome 1

( Socket Design )
Trans-tibial
Prosthetics
Course Work Manual
ICRC
( INTERNATIONAL COMMITTEE OF THE RED CROSS )
Aknowledgements
Substantial parts of the information and reference material provided in This Technical Manual
for Lower Limb Prosthetics has been compiled from various medical and university sources.
Without their long practice, know-how and extensive publications, this manual would simply
not exist. We would like to mention in particular:
Course Work Manual, Carson Harte and Anne Henriksen, National School of Prosthetics
and Orthotics from Phnom Penh, Cambodia:
- Partial foot prosthetics
- Ankle disarticulation prosthetics
- Below knee prosthetics
- Knee disarticulation prosthetics
- Above knee prosthetics
- Hip disarticulation prosthetics.
Clinical aspects of Lower extremity prosthetics, Trans-tibial, Symes and Partial foot
amputations, The Canadian Association of Prosthetists and Orthotists.
Trait dAnatomie Artistique, Dr. Paul Richer, Inter livres.
Lower Limb Prosthetics, 1990 revision, New York University Medical Centre.
Lower Limb Prosthetics, 1990 revision Prosthetics and Orthotics, New York University
Post Graduate Medical School.
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Trans-tibial Prosthetics
INDEX
Section Pages
1 Biomechanic Principles for PTB Socket Design 2
2 Surface Anatomy Of Lower Extremity 11
3 Patient Assessment 16
4 Measurements & Casting Techniques 30
5 Cast Modification 51
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SECTION - 1
BIOMECHANICS PRINCIPLES FOR
THE PATELLAR TENDON BEARING
(PTB)
SOCKET DESIGN.
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BIOMECHANICS OF SOCKET FIT
Comfort, stability and function of a prosthesis are achieved primarily by the
application of certain biomechanical principles. In the past, the application of these
principles has been based upon clinical experience and trial and error. In more recent
years, the contributions of a number of investigators have provided a clearer
understanding of some of these biomechanical factors. The purpose of this chapter
is to relate selected biomechanical principles to socket shape of the below-knee
prosthesis, with special reference to the patellar-tendon-bearing below knee
prosthesis.
Pressure as a Determinant of Comfort
The magnitude of pressure between the stump and socket is one of the major
determinants of comfort in a prosthesis. Pressure is directly proportional to the force
applied and inversely proportional to the area over which it is applied. This is
expressed in the formula P=F/A, in which P represents the average pressure, and F
and A represent, respectively, the applied force and the area over which the force is
applied.
P=F/A
The force F is expressed in kilogram and represent the weight the patient is bearing
on the prosthesis. The area is expressed in square centimetres and represent the
surface applied by the socket on the stump.
To minimize discomfort, it is important to avoid excessive pressure on the stump.
There are two way to reduce the pressure. First you can reduce the amount of force
apply on the stump by reducing the weight. Second you can increase the area over
which the force is applied. To reduce the force exercised on the stump by the
prosthesis you must use external means such as a thigh corset, crutches or other
similar means. To increase the area, you must use all the possible bearing surface
of the stump. Although for the first approach, it is easy to do, it is rather cumbersome
and does defeat the ultimate means of the prosthesis to make the patient as
autonomous and functional as possible. As for the second approach, in practice it is
not that simple because the relative firmness or softness of the tissues of the stump
are not uniform. As well, some areas of the stump tolerate pressure quite well, while
other areas are relatively sensitive to pressure. However, both of these factors can be
accommodated by appropriate design of the contours and shape of the socket.
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To start with a general concept, consider Figure 1.3, which represents a heavy bar
resting on a cube. The pressure on top of the cube is equal to the weight of the bar
divided by the area of the cubes upper surface. Figure 1.4 shows the same bar being
supported, not only on the original cube, but by two additional cubes identical to the
original and at equal distances from it.
Socket Contours and Shape Related to Pressure Distribution
Figures 1.1 and 1.2 show top views of contours of the socket walls of two different
types of below-knee prosthesis. Figure 1.1 is derived from a PTB socket, while
Figure 1.2 is derived from a type of socket that was fitted before the PTB socket
came into general use. Although the socket periphery of Figure 1.1 conforms more
closely to that of the below-knee stump than is the case with the PTB socket, the PTB
socket is generally the more effective of the two from the standpoint of comfort and
function. It is important to understand the reasons for this and, in general, to
understand the principles that relate socket contours and shape to pressure
distribution.
Fig. 1.1 Fig. 1.2
Fig. 1.3 Fig. 1.4
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In this case the pressure on the middle cube will be only one-third as great as in
Figure 1.3, since the supporting area is three times as great. These two examples
illustrate the application of a basic principle in prosthetic fitting, and that is to utilize
as much area of the stump as possible to distribute the force applied by the socket to
the stump.
By cutting a slot, or relief, in the steel bar, as shown in the middle diagram of Figure
1.5, a more even distribution of pressure would be obtained, in spite of the
differences in relative firmness of the steel and rubber cubes. However, if the rubber
cubes were very soft, the relief alone might not be enough to produce the desired
distribution. To illustrate, suppose the steel bar had a mass of 200 kg and the rubber
cubes were so soft that a mass of 15 kg compressed them so that the steel bar came
to rest firmly on a steel cube in the middle. Then the steel cube would have to support
a mass of 170 kg as opposed to the 15 kg supported by each of the rubber cubes.
Accommodating for Differences in Relative Firmness
In most cases, various areas of the stump will differ in relative firmness. If an object
in fitting is to distribute pressure evenly over these areas in spite of different degrees
of firmness of the tissues, then modifications of socket contour with respect to the
stump become necessary. The next series of illustrations demonstrates the principles
involved.
If the cubes in Figure 1.4 had the same dimensions, but differed in their relative
firmness, the pressure would not be distributed evenly. For example, if the middle
cube were made of steel and the other two were made of soft rubber, the steel cube
would support most of the load.
The load distribution could be improved by cutting a deeper relief in the steel bar.
Since this might weaken the bar, an alternative solution might be used. Instead of
making the relief deeper, two build-ups could be added to the bar, as shown in
Figure 1.6. If the relief were cut to the proper depth and build-ups of the proper
thickness were applied, an even distribution of pressure would be obtained.
Fig. 1.5
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Now apply this to a prosthesis. The diagram in Figure 1.7 is a schematic
representation of a stump that is essentially circular in cross-section, encased in a
socket that accurately matches the periphery of the stump. If the stump were of
uniform firmness, the stump-socket pressure would also be uniform. The diagram in
Figure 1.8 is similar to Figure 1.7, except that the stump is not of uniform firmness.
The areas indicated by the letter F are relatively firm, while softer areas are
indicated by the letter S. This, of course, is a schematic diagram.
If the socket were shaped to match the stump accurately, the pressure on the stump
would not be evenly distributed. The firm areas Fig 1.8 designated by F would
take relatively more of the load, while the soft areas designated by S would take
relatively less. A more even distribution of pressure could be obtained by purposely
modifying the socket to make reliefs in the socket over the firm areas and bulge the
socket inward over the soft areas, as shown in the diagram in Figure 1.9.
Fig. 1.6 Fig. 1.7
Fig. 1.8 Fig. 1.9
.
.
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Accommodating for Different Tolerance to Pressure
The same strategy described above, namely that of utilizing reliefs and inward
contours in the socket, can be used to compensate for different tolerance to pressure
of the various areas of the stump. In this case the purpose is different. Instead of
producing an even distribution of pressure, the objective is to produce a selective
loading of the tissues so that more of the weight will be supported by the pressure-
tolerant areas and less weight will remain on the pressure- sensitive areas.
To illustrate, the three cubes in Figure 1.10 have the same dimensions and the same
degree of firmness. Assume that the cube in the middle is pressure-sensitive and the
other two cubes are pressure-tolerant. The objective is to load the end cubes
selectively so that less weight will remain to be supported by the middle cube. If a
heavy bar were placed on the cubes, as shown in Figure 1.10, the same amount of
weight would be borne by each cube. This is not what is wanted. By cutting a relief
in the steel bar, as shown in Figure 1.11, a more desirable weight distribution can be
obtained. If the relief alone is not sufficient, build-ups may be added, as shown in
Figure 1.12. By making the reliefs and build-ups of proper dimensions, almost any
proportional distribution of weight on the three cubes can be obtained even to the
point of completely unloading the middle cube.
Fig. 1.10
Fig. 1.12 Fig. 1.11
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The application of this principle can now be illustrated. Figure 1.l3 is a schematic
diagram of a stump of uniform firmness, encased in a socket. The socket has reliefs
over the pressure-sensitive areas, which are designated by S, and inward contours
over the pressure- tolerant areas, which are designated by T. The inward bulges
over the pressure tolerant areas will cause the tissues in these locations to sustain a
relatively large portion of the load, leaving a smaller part of the load to be borne by
the sensitive areas. The reliefs in the socket will assist further in reducing the
pressure sensitive areas.
Sockets of both below knee and above knee prostheses are usually designed to apply
the biomechanical principles illustrated above. By incorporating appropriate reliefs
and contours, sockets can be shaped to accommodate differing degrees of firmness
of the stump and different tolerances to pressure.
The typical patellar-tendon-bearing prosthesis for the below knee amputee has an
inward protuberance that fits under the patellar tendon and a snug contour that fits
under the medial flare of the tibia. The posterior wall bulges inward slightly, and
the lateral wall is shaped to provide firm pressure on the lateral distal half of the
stump. Reliefs in the socket are usually provided for pressure-sensitive areas at the
anterior distal aspect of the stump, over the crest of the tibia and over the head of
the fibula.
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Effect of Relative Inclination of Supporting Surface
Pressures on the stump are greatly influenced by the relative inclination of the
supporting surfaces that are in contact with the stump.
In applying this principle, it can be seen that a horizontal supporting surface in a
socket is preferable to a steeply inclined supporting surface. In the socket of a below
knee prosthesis, except for the Symes amputation, a horizontal surface to which a
major part of the load can be applied is not available. While the bottom of the socket
for a mid-leg amputation may be approximately horizontal, the end of the stump can
hardly tolerate pressure, let alone heavy loading. If the below knee stump is fitted in
a socket in which the steeply inclined walls provide the major supporting surface, it
is usually necessary to support part of the weight by means of a thigh corset because
of the excessive pressure that would be generated if all the necessary supporting
force had to be applied to the stump by the socket walls. The thigh corset transmits
part of the load via the side bars and knee joints to the shank of the prosthesis, with
a corresponding reduction in the amount of the weight that must be supported by the
socket in contact with the stump.
The thigh corset is somewhat bulky
and tends to produce atrophy of the
thigh. By fitting the stump in slight
initial flexion and by purposely
modifying the contour of the socket by
making an inward bulge to fit under the
area of the patellar tendon, an effective
weight bearing area is made available,
as shown in Figure 1.14. While this
area is not horizontal, it is much less
steeply inclined than the other support-
ing areas of the socket wall. The
corresponding reduction of the load
that must be supported by the steep
walls of the socket makes it possible, in
most cases, to dispense with the thigh
corset and to suspend this type of
prosthesis with a supracondylar wedge
or, less efficient, with a strap.
Fig. 1.14
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Although the supporting area of the patellar tendon is less steeply inclined than the
other supporting areas, it still has a downward and backwards slope. The stump,
supported on this area tends to slide downward and backward. To prevent this, an
anteriorly-directed counter-force is required. The anteriorly-directed counter-force
is applied by the posterior wall of the prosthesis. The posterior wall should be
relatively high to provide as much area as possible over which to distribute the
counter-force, but it must not be so high that it interferes with sitting comfort. It is
not enough for the posterior wall to match the posterior aspect of the stump. The
posterior wall of the socket must be flattened, or even have an inward bulge, so that
the tissues with which it is in contact are under some initial compression. If this was
not done, the stump would tend to slide downward and backward until the tissues on
the posterior aspect of the stump were compressed sufficiently to provide a counter-
force to arrest the motion. Also, the bony surfaces on each side of the posterior
aspect of the stump would bear too much pressure.
A well contour of the socket in the area of the medial flare of the tibia can provide
an effective weight bearing area. To maintain the stump on the inclined surface, a
counter-force must be supplied by the lateral wall of the socket to the lateral aspect
of the stump. The major part of this counter-force will be applied to the distal half
or distal third of the stump.
Total Contact Sockets
The socket of the PTB prosthesis is designed to provide total contact with the stump.
Prior to the development of the PTB prosthesis, a majority of trans-tibial sockets did
not provide contact of the socket with the end of the stump. From a biomechanical
standpoint, the total contact design is generally preferable because it offers the
following advantages:
1. It helps to prevent oedema and aids venous return. This is the most important
advantage. In the intact limb, the pumping action of the muscles is an important
factor in moving venous blood back toward the heart. In the amputated limb this
important pumping action is reduced. There is a tendency for oedema to develop in
the dependent stump unless pressure is applied to the entire stump.
2. The total contact socket provides greater area over which to distribute the load.
Even though the load supported by the end of a mid-leg or mid-thigh stump is not
great, it does decrease to some extent the load that must be borne by the other areas
of the stump.
3. Because it is in contact with a greater area of the stump, the total contact socket
probably provides better sensory feedback to the wearer.
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SECTION - 2
SURFACE ANATOMY
OF THE LOWER EXTREMITY
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BELOW KNEE - SURFACE ANATOMY
Bony structures to be identified:
- Femoral condyles
- Femoral epicondyles
- Tibial condyles
- Medial Tibial Plateau
- Adductor Tubercle
- Patella
- Tibial Tuberosity ( tubercle )
- Lateral Tibial Tuberosity
- Head of Fibula
- Tibial Crest
- End of Tibia
- End of Fibula
- Medial Tibial Flare
- Tibialis Anterior
Muscles to be identified:
- Tibialis Anterior
- Gastrocnemius
- Quadriceps Femoris
- Patellar Tendon
- Hamstrings
- Biceps Femoris
- Semimembranosus
- Semitendinosus
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LateralFemoral Condyles
Medial Femoral
Condyles
Lateral Femoral Epicondyles
Lateral Tibial condyles
Medial Tibial condyles
- Medial Tibial Plateau
Adductor Tubercle
Patella
Patella
Tibial Tuberosity
( tubercle )
Tibial Tuberosity
( tubercle )
Lateral Tibial
Tuberosity ( tubercle )
Head of Fibula
Tibial Crest
Distal End of Tibia
Distal End of Fibula
Medial Tibial Flare
Patellar Tendon
Bony structures of the below knee stump (anterior-lateral view)
Bony structures of the below knee stump (anterior-medial view)
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Tibialis Anterior
Medial Tibial Flare
Head of Fibula
Patella
Lateral malleolus
Medial malleolus
Tibial Tuberosity ( tubercle )
Quadriceps Femoris
Front of right lower extremity
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Popliteal Fossa
Biceps Femoris
Gastrocnemius
Semitendinosus
Semimembranosus
Hamstrings
Gluteus maximus
Tensor fasciae latae
Gluteal fold
Medial malleolus
Tendo calcaneus
Back of left lower extremity
Soleus
Lateral malleolus
Perona longus & brevis
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SECTION - 3
PATIENT ASSESSMENT
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PATIENT ASSESSMENT
Introduction:
To carefully examine the patients stump is a very important part of the Prosthetists
work. The examination will tell if the patient is ready for treatment or not. Also the
examination will be a factor in deciding what type of prosthesis to prescribe and the
type of special considerations to make.
The importance of keeping carefully a record for each patient cannot be
overemphasized. It help you to be more accurate, and more professional, in your
decisions leading to the fabrication of the prostheses. It is also primordial for
references when discussing with other rehabilitation members as well as with the
relatives.
Below are descriptions of different conditions of the stump that will be helpful to
record.
Abrasions.
Are caused by rubbing between the prosthesis and the skin. They should not be a
factor in the new fitting. Abrasions may take the form of blisters or raw skin surfaces.
Boils and other skin infections.
Pus-filled infections, with a core of dead tissue, that occur, usually around a hair
root. Medical care may be required before a prosthesis is fitted.
Bone Spurs.
Bony outgrowths, that may often be found by palpation. The most common region
of spur formation is the end of fibula, in below knee stumps.
Bursa.
A sac filled with a thick fluid, it lies under the skin and over bony prominence.
Bursae are located over the patella and around the tendons of the knee. When there
is too much pressure and movement over them, they get bigger, sometimes only for
a short period of time. Bursae may become infected and require medical treatment
or a change in the prosthesis.
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Discoloration.
Often skin which has had too much pressure, has been damaged by bruising or
oedema, has an abnormal colour.
Pressure first reddens and then after several weeks, toughens and darkens the skin to
brown.
Bruises causes blue, yellow, green or brown colours. These show that blood is in the
deeper layers of the skin.
Oedema reddens the skin, if it occurs for long periods it results in blue colours and
finally in the case of chronic oedema, brown stains are left. These stains fade slowly
and may disappear.
Colours of the skin is the most useful guide to show areas of pressure, and may
indicate to the Prosthetist that pressures in the socket should be changed.
Oedema.
A collection of fluid in soft tissues of the stump. May be postoperative or may be
caused by a poorly fitting prosthesis. ( e.g. constriction proximally.)
Oedema should be reduced, with an elastic bandage as much as possible before
fitting is done, otherwise the socket becomes loose too soon.
Pressure point.
An area of the stump that is painful when pressure is applied. An example is the area
where the peroneal nerve passes over the lower surface of the fibular head. Such
points usually require relief in the socket.
Scars.
There are two types of scar tissue:
- Atrophic - thin and easily damaged.
- Hypertrophic - Thickened, painful and often stuck to the bone.
All scar tissues tend to be inelastic, and care must be taken to make sure that it is not
stretched or rubbed. When stretched it may tear.
When the scar sticks to the bone it may be possible to loosen it by movement and
massage.
If there is no piston action it may be possible to apply constant pressure over a larger
area of scared tissue.
Trigger points.
A sensitive spot on the stump that causes pain even if it is only touched tightly. Often
constant pressure can be tolerated.
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Stump shape.
The stump may be described as bulbous, cylindrical or conical.
The conical stump shrinks the least.
The bulbous stump shrinks the most in the distal portions. It also may require an
extra build up on your liner in order to make the donning of the socket easier.
Distal padding.
The amount of tissues covering the cut end of the bone may differ very much.
When the cover is thin it is important to be careful when fitting. Stumps with heavy
distal cover should especially be fitted with total contact sockets to reduce the risk
of oedema.
Condition of subcutaneous tissue.
The condition of the tissues underneath the skin will give a guide to tissue shrinkage.
The tissue is pinched lightly between two fingers and if it can be described as heavy,
then more shrinkage can be expected than if it is described as light.
Also the muscles of the stump are used as a guide to rate of atrophy. A large mass of
muscles will start to atrophy very quickly where as firm musculature will take longer
to atrophy.
Pain.
Pain is described by location, degree and sensation experienced. It may be caused by
some condition in a different place from where the patient feels it.
It is important for the Prosthetist to find out if the pain is caused by the prosthesis or
by a condition within the stump.
Condition of the knee joint.
When describing the condition of the knee joint - range of motion, joint stability,
muscle strength, patella and contractures are included. Although the prosthetist has
to look at those conditions, the physical therapist is usually the most apt to perform
the evaluation of the knee.
Range of motion:
If the range of motion is reduced the Prosthetist may either make the socket
brims higher to ensure no extra movement. Or if medically indicated the fit
and alignment may be made to increase the range of movement.
Also range of motion of the hip joint may effect the fitting of a prosthesis.
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Joint stability:
Sometimes the knee joint is easily dislocated or very unstable medio-
laterally, as a cause of injury or a congenital condition.
Suspension and socket type should be chosen accordingly to the type and
degree of instability.
Muscle strength :
It is important to know how strong the muscles of the knee and hip are in
order to know if the patients weight can be supported, and if the muscles are
strong enough to control the knee.
Patella:
Sometimes the Patella has been removed or it is split. This will only be a
problem if it affects the possibility of weight bearing at the tendon.
Contracture:
It will not be a problem unless it is severe. The aim of the prosthetic fitting
is not to reduce contractures, although in some case, in cooperation with the
physical therapist, it can help to reduce the contracture.
Condition of the cut end of bones:
Usually the fibula is shorter than the tibia. If fibula is longer than tibia, it is usually
very sensitive and care must be taken in fitting.
In some cases the fibula moves with knee flexion, but this should not be a problem
in a good fitting socket.
The tips of the bones may initially be sharp and care must be taken during fitting.
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EXAMINATION OF THE KNEE.
RANGE OF MOTION:
With the patient sitting on a flat firm surface, check the range of motion of the knee
joint.
Normal range of motion:
Flexion 130
Extension 0 - 10
The most common problem with knee range of movement is the knee flexion
contracture ( the knee cannot extend fully ).
A knee flexion contracture is
measured by measuring the
angle between the midline of
the thigh and the midline of
the stump.
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If there is some medial - lateral looseness, care must be taken to make a socket
that supports the knee medio-laterally, e.g. supracondylar support. Or if the
instability is extremely severe a thigh corset can be added to the prosthesis.
KNEE JOINT STABILITY:
The Medio - Lateral stability ( Collateral ligaments ) is checked by applying valgus
and varus stress to the joint. The patient is sitting with the stump extended.
The medial collateral ligament is loose, if the
knee joint can be opened on the medial
side.
The lateral collateral ligament is loose, if
the knee joint can be opened on the
lateral side.
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KNEE JOINT STABILITY:
The Anterior - Posterior knee stability ( Cruciate ligaments ) is checked when the
patient sitting with a flexed knee.
The Prosthetist pulls the lower leg anteriorly
and if movement is detected the patient has a
loose or torn anterior Cruciate ligament.
If movement is detected when the lower
leg is pushed Posteriorly, the patient has a
loose or torn posterior Cruciate ligament.
The most common problem with anterior - posterior instability is that there is
a tendency for the knee to hyperextend ( extend too much ) This could be helped
by making either a socket with supra patellar support or if the problem is
severe, adding a thigh corset to the prosthesis.
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MUSCLE STRENGTH:
The patients muscle strength of the knee extensors is checked by asking the patient
to extend the knee while the prosthetist is resisting this movement.
The main knee extensor muscles are:
Quadriceps - Rectus femoris,
Vastus lateralis,
Vastus intermedius,
Vastus medialis.
The strength of the knee flexor muscles is checked by asking the patient to flex the
knee while the prosthetist is resisting this movement.
The main knee flexor muscles are:
Hamstrings - Semimembranosus,
Semitendinosus, Biceps Femoris.
NB. The muscle strength evaluation, as
most of the other tests for the knee and
hip problems, is better done by the
physical therapist.
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EXAMINATION OF THE HIP:
RANGE OF MOTION:
To make an accurate assessment of the hip it is necessary to have the patient lye
down on a couch. This is to avoid any movement of the pelvis, because this
would show a false impression of hip joint movement.
Let the patient lie on his / her back to test for hip adduction, abduction and
flexion as illustrated below. And let the patient lie on the front / stomach to test
for hip extension ( see illustration )
Normal range of motion:
Flexion 130 Extension 30
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The most common problem with range of movement at the hip joint for
amputees is that there is a hip flexion contracture ( the hip is stuck in some
degree of flexion ) This can accurately be measured by using the - Thomas Test
- as described on the following page.
Normal range of motion:
Abduction 45-50 Adduction 20-30
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Thomas Test
The Thomas Test for flexion contracture of the hip.
With the hip flexed, the lumbar spine flattens
and the pelvis is stabilized. Further flexion can
only originate in the hip joint.
A fixed flexion contracture is caractherized by
the inability to extend the leg straight without
arching the thoracic spine.
The extend of a flexion contracture can be de-
termined by estimating the angle between the
table and the patients leg.
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MUSCLE STRENGTH:
Strength of hip flexion muscles is tested by having the patient sit on a firm surface.
He / she flexes the hip ( lift the thigh up on the seat ) while the prosthetist is resisting
the movement and assessing the strength.
The main hip flexor muscles are:
Iliopsoas.
Strength of hip extensor muscles is tested by having the patient lie on a firm
surface, lifting the leg a little and then extending it ( moving the thigh away from the
couch ) while the prosthetist is resisting the movement and assessing the muscle
strength.
The main hip extension muscle is:
Gluteus Maximus.
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MUSCLE STRENGTH:
Strength of hip abduction muscles is tested by having the patient lie on the
side lifting the leg to be tested up from the couch, the prosthetist resists this
movement and assesses muscle strength.
The main hip abductor muscle is:
Gluteus Medius.
Strength of hip adduction muscles is tested by letting the patient lie on the
back adducting both legs while the prosthetist resists the movement.
The main hip adductor muscles are:
Adductor Longus,
Adductor Brevis,
Adductor Magnus.
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SECTION - 4
MEASUREMENTS
&
CASTING TECHNICS
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MEASUREMENT & CASTING TECHNIQUES
FITTING AIDS
Fitting aids may include a tracing of the stump, record of circumference, length and
diameter measurements of the stump and sound shank, some angular measurements
of the stump, and most important of all a plaster cast.
STUMP MEASUREMENTS
The measurements can be of two or three dimensions. Although the stump is a
volumetric mass of three dimensions, in practice we are recording mainly two
dimensions measurements. The cast is a three dimensions measurement. This is why
the measurements will never be as accurate as a well applied cast. Their accuracy
depends on the condition of subcutaneous tissue, musculature, size of stump, and the
skill and experience of the prosthetist with regard to how much tension to apply on
the measuring tape. However, measurements are useful as a reference for later.
Two dimensions measurements
Linear measurements: Circumferences, diameters and length or height
(See Measurements Assessment Chart )
Angular measurements: Usually for contracture of the stump.
Circumferential:
Although it is a common practice to take the circumference at mid patellar level, it
is awkward to use that measurement as a reference on the positive mould. The
postero-proximal reconstruction on the cast render impossible to keep the tape
perpendicular to the longitudinal axis of the stump. Plus we have a severe
modification at the PTB level. It is more practical to take this first circumference 2,5
cm below the mid PTB. This way there is no interference when referring to it on the
mould and it is just below the deep indentation of the PTB.
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Diameters
-The following measurements are needed to aid in modification of the plaster cast:
1) At the patellar tendon level - an AP measurement taken from mid-tendon to the
popliteal region between the medial and lateral hamstrings. This should be taken
with the knee in 10 - 15 degrees flexion. Here you can take two diameters, one
without pressure and one with firm compression. This way it helps you to judge the
value of the force used. The difference between those two diameters should be
around 1.2 to 1.5 cm.
2) Just above the femoral condyles - an M-L measurement to be used for the
supracondylar suspension. This supracondylar measure should be made as tight as
tolerable.
* If you are making a suprapatellar socket, you can take the A-P measurements at that
level.
3) At the patellar level - an M-L
measurement of the femoral condyle,
to its widest point. Usually taken
without compression. If there are soft
tissue, the tissue should be compressed
to about half of its thickness.
4) Optional. You can take the M-L
measurements from the flare of the
tibial condyle to just superior to the
head of the fibula.
Diameter measurements of the normal shank are useful for cosmetic shaping of the
prosthesis.
Fig. 4.1
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Lengths
-The three most important length measurements are as follows:
1) Length of stump - taken from the tibial plateau, or the axis of rotation of the knee
(adductor tubercle), to the most distal aspect of the stump.
2) Length of tibia - taken from the tibial plateau to the distal end of the tibia.
3) The mid PTB of the normal shank or the knee centre - taken from the axis of
rotation of the knee (adductor tubercle) to the floor, barefoot. The amputee should
be in a seated position, with foot flat on the floor and knee flexed at 90 degrees.
Angular
For the BK prostheses, we take mainly the degrees of flexum (contracture in flexion)
of the stump if there is such a contracture.
Length and circumference measurements are taken of the sound foot. Heel height is
recorded. The firmness of the prosthetic heel is determined by the patients weight
and activity level.
Other measurements worth of taking are measurements of the prosthesis the patient
is actually wearing, particularly the AP and the M-L of the socket.
*When you are taking measurements, try to always use reference points you can
easily relocate at any time. Keep the same approach and always use the same tools.
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Before taking the measurements, sit the amputee on a firm bench or table, just as you
would do for taking the cast. His thigh supported, the back of his knee approximately
10 cm from the edge of the table, and the knee is 15 to 20 degrees of flexion. The
midline of the thigh on the amputated side is perpendicular to the front edge of the
table (Figs. 4.3 & 4.4).
A moistened cast sock is pulled over the amputees stump. If the patients stump is
very hairy, spread vegetable oil or other lubricant over the stump. This will avoid the
unpleasant experience of peeling the hair while removing the cast later. (Do not used
industrial lubricant for machinery or car to avoid allergy reaction.) Care must be
taken to avoid posterior displacement of the tissue at the distal end of the stump. Any
tension or stress on the suture line and anterior aspect of the tibia is undesirable. An
elastic strap, which passes around the amputees pelvis is clamped to the superior
medial and lateral sides of the sock as shown in Figure 4.2.
Check the fit by pinching a fold in the sock, pulling it away from the stump, and
releasing. It should snap back to the stump. The cast sock should be fitted snugly and
should not move during the measurement and the casting.
Procedure for Measurements
Material needed:
Tape measure, callipers, meter stick, goniometer.
Indelible pencil, a pen and measurements charts.
Thin cast sock
Two meters length of elastic webbing
Two harness clamps
20 knee- flexion angle template
Using the measure chart provided take all the measures carefully filling in all the
boxes.
The sections marked Personal Data and Manufacturing details are equally important
since they will communicate your decisions to the workshop or technician who will
manufacture the limb.
Pay special attention to the area recording socket position. Measure and record any
deformities. These will allow the accurate bench alignment (initial alignment) of the
socket at a later stage.
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A good stump sock is the basis of a good cast, sound measurements and the tracing
if needed.
1/ It controls the soft tissue holding it in place.
2/ It gives a place to write marks over the stump, and later, allows the references
marks to be transferred on the positive mould.
10cm
Fig. 4.3 Fig. 4.4
Fig. 4.2
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Circumferences
Before taking the circumferences, use an indelible pencil and mark on the sock the
exact location for those measurements. Also you may as well draw all the reference
marks on the stump (see casting reference marks).
When taking the circumference measurements, you must make sure that the
measuring flexible tape is perpendicular to the longitudinal axis of the stump.
*If you must provide a thigh corset with the prostheses, You must take the thigh
circumferences as indicated on the form. The first thigh circumference is
immediately above the patella. The other one should be as proximal to the groin as
you are planning to terminate the corset.
Diameters
Make sure you are using the calliper properly to avoid inducing errors of reading .
*The diameters of the thigh should also be taken if you have to provide a thigh corset.
Lengths
When you take the lengths, make sure the stick is always parallel to the longitudinal
axis of the segment you are measuring.
Angle
Only if there is flexion contracture of the stump or the hip.
The Sound Leg Measures will determine the accuracy of the set up of the leg prior
to fitting and the cosmetic appearance of the leg.
The old prostheses measurements can be taken at another moment, but should not be
forgotten.
All measures, except for the supracondylar ML diameter and the AP diameter at the
PTB level, should be taken without deforming the soft tissue with the tape measure,
or callipers. Accurate and repeatable measures are essential.
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Tracing.
Tracing of the stump contours can
be taken just before the cast or the
measurements. The amputee is
sitting in the same position as for
measurements or casting, with the
casting sock in place. Position a
sheet of paper or a cardboard under
the stump and draw the contours of
the stump. Mark some reference
points on the tracing and on the sock
with the indelible pencil.
To avoid any distortion of the shape
of the stump, you must:
1- Make sure you are not widening
the form by pressing the cardboard
on the back of the stump;
2- Hold the tracing pencil
perpendicular to the paper at all
time.
The most important tracing is the
one in the frontal plane, i.e. view
from the front. But you can also take
one from the coronal plane, i.e. side
way.
After the cast is done, using the reference measurements, correct the tracing and cut
it out. Verify on the stump of the patient if it is appropriate. Later on you can use the
tracing to verify the correctness of your cast during the modifications.
This approach is particularly important for beginner. In practice, it is so common
to loose the shape of the stump while taking the cast or modifying it.
We used to make a tracing of the sound leg both from the front and from the side.
Although it can be helpful for the final shaping of the prosthesis, it is rather
cumbersome to carry this big sheet of paper around. If you really need that kind of
accuracy for the cosmetic, the use of polaroid picture is less cumbersome and as
efficient. If the latter is not available, try to have the patient present when you sculpt
the leg. This way, you can compare before finishing the prosthesis.
Fig. 4.5
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BELOW KNEE CASTING PROCEDURE
Aims
The aim of fitting a good BK socket is to achieve comfortable total contact. At the
same time carrying most of the patients weight on the areas of the stump which can
tolerate pressure and protecting the areas which cannot.
Presently, the plaster cast is still the most common way used to achieve this goal. If
well carried out the rectification process that will follows will be much easier and the
final fit of the socket will be good.
Materials required.
Material for the measurements plus the following:
1. 2 to 3 rolls of plaster bandage; 15 or 20 cm
2. Elastic bandage.
3. Grease.
4. Scissors and cast cutter if required.
Casting Technique
Cast wrapping of the amputees stump for the fabrication of a socket is the most
important part in the procedure of fitting and constructing a prosthesis for the trans-
tibial amputee. There is no substitute for this procedure, or for skilful, experienced
hands. A cast well taken will require little modification of the positive plaster , and
thus reduce any chance of error.
The importance of a well taken cast cannot be overemphasized. The best possible
adjustments and alignment will never overcome the problems created by a poorly
fitting socket. A well fitting socket is the foundation of success, and it does start with
a well taken cast.
*We have chosen to describe a casting technique for the PTB SCSP (Patellar
Tendon Bearing Supra Condylar Supra Patellar) over the regular conventional
PTB tibial prostheses. In the context of the ICRC working with soft Alvelux insert
and polypropylene, the PTBSC and the PTB SCSP are probably the most efficient
way to make a BK socket with adequate suspension while providing decent stability
of the knee. The supracondylar wedge suspension is far superior to the use of
supracondylar strap. It does keep the pistonning action of the prostheses to a
minimum. Furthermore, it reduced the need for a waist belt. Finally, it gives enough
medio lateral stability that only a few amputees do require a thigh corset.
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CASTING PROCEDURE
The casting technique we will be describing is known as a two parts cast for the PTB
SCSP. The reason we choose this two parts approach over the one step, is mainly
because it is much easier to control all the different details of the casting. This is
particularly important for the beginner. The one step casting method, although
faster, has just too many details to be controlled at once for a beginner. Also, the two
parts approach cast is easier to remove from the patient. Finally, the cast remains
more intact, i.e. without losing its initial shape, while being removed.
Just after taken the measurements, the amputee is still seated on a firm bench or
table, with his thigh supported, the back of his knee approximately 10 cm (Fig. 4.6)
from the edge of the table, and the knee is 20 degrees (Fig.4.8) of flexion. During the
entire wrapping sequence, the knee joint should be held in position of 20 of flexion
so as to emphasize bony prominences, aid in the definition of the patellar tendon,
and assist in locating the hamstring tendons.
You can use a 20 template to position the stump and instruct the patient to hold this
attitude with minimum muscle tension.
Before starting, make sure you have the material and tools required for the casting.
Position yourself in front of the stump and sit lower than the amputee. This will help
you to obtain a better cast.
20
10cm
Fig. 4.8
Fig. 4.6
Fig.4.7
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Reference marks:
A. Outline of the patella.
B. Middle of the patellar tendon mark with a horizontal line midway between the
distal pole of the patella and the superior border of the tibial tubercle.
C. Outline the head of the fibula.
D. Anterior border of the tibia (tibial crest).
E. Medial border of the tibia.
F. Outline the anterior distal end of the tibia.
G. Outline the distal end of the fibula.
H. The inferior border of the medial flare of the tibial condyle.
I. The inferior border of the lateral flare of the tibial condyle.
J. The femoral epicondyles
In addition, marks should outline any areas of the stump that require special
treatment because of prominence, sensitivity, or other reasons.
Pay particular attention to:
-The outside borders of the medial and lateral hamstring tendons;
-The anterior prominences of the lateral and medial tibial condyles;
-An unusually prominent tibial tubercle;
-Bone spurs,
-Adherent scars, neuromata, and any other sensitive areas.
When accurate stump marks have been made we are ready for the cast.
Fig. 4.9
a
b
f
c
i
d
g
j
h
e
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CASTING STAGE
1/ Using a 15 or 20 cm plaster bandage the stump is wrapped carefully. Some
prosthetists begin the wrapping proximally while others prefer to start distally.
Elasticized plaster bandage (10 cm width) would be preferable as it conforms more
readily to the stump. As this is not available, we can later compensate by using an
elastic bandage over the cast. The upper edge of the bandage should be positioned
1 to 2 cm over the lower edge of the patella. If you go any higher, it will be difficult
later to get an accurate moulding of the supracondylar.
2/ Wrap the bandage firmly around the stump at right angle to the longitudinal axis,
until the plaster is three layers thick. Firm, even tension must be maintained so that
the triangular shape of the anterior aspect of the stump is retained, and the loose flesh
is not pulled posteriorly with the bandage.
3/ Proceed to wrap the cast down the stump eventually taking in the distal end. A
good technique, at this point, is to use the figure 8 approach.
4/ The cast should not be so tight as to cause rucks and lines.
At all times during the wrapping care should be given to the smoothing and moulding
of the cast.
Because ICRC is not using elastic plaster bandage, the use of an elastic bandage
over the plaster bandage is an excellent way to compress the cast and to obtain a
more accurate mould. The elastic bandage can be reused over and over, as long as
you wash it after using it. You can even pull a stockinet over the cast in order to keep
your elastic bandage cleaner.
5/ The plaster wrap is worked
with both hands. Smooth the
plaster over the surface of the
stump by moving the hand from
anterior to posterior around the
stump, and from distal to
proximal. Mould the plaster
around bony prominences so that
they are clearly defined, but
avoid to overwork it as the plaster
begins to harden. The prosthetist
should avoid making any sharp
indentations with his/her fingers
in the plaster wrap.
Fig. 4.10
44
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As mentioned previously, the knee joint must be maintained in 20 of flexion
throughout the casting procedure. The prosthetist should check this repeatedly and
instruct the amputee to hold this position with a minimum of muscular tension.
Contraction of stump musculature can distort the wrap cast.
6/ As the plaster begins to set position the thumbs on either sides of the patellar
tendon as shown in the diagram and press in firmly. The thumbs must be at a 45
angle to the long axis of the tibia. Be sure to bend the interphalangeal joints of the
thumbs so that only the thumb tips touch the wrap, as shown in Figure 4.11. Be
careful not to impinge on the inferior border of the patella nor on the anterior
proeminences of the tibial condyles.
Wrap the 3rd, 4th, and 5th fingers around the stump so that the tips of the fingers
apply moderate pressure in the centre of the popliteal area. If there is doubt about
location of the tendon, use the stump-length measurement taken in Step 5 as a check.
Remember, all that must be done before the plaster has too hardened.
S em i te nd in o s us te nd o n
S em i m em b r a n os u s te n d on
G r a c ili s te n do n
S ar t or ius te n do n
B i ce p s f e m o r is t en d on
P at el la r te n d on
Fig.4.11
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The upper (3rd) finger should be approximately 1.2 centimetres distal to the thumbs
(Fig. 4.12). Be sure the finger tips are centred in the popliteal area and that the
hamstring tendons are not compressed.
The remaining finger (index or 2nd) extends on each side of the wrap and helps to
resist any tendency toward mediolateral bulging (Fig. 4.13).
You should press hard enough to get a good identification of the spots yet not too
much as to enlarge the M-L of the stump. Good care should be taken to keep the M-
L of the cast as close as possible to the M-L of the stump.
1
.
2

c
m
Fig.4.12 Fig.4.13
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Supracondylar casting.
1/ Make up a slab of dry Plaster of Paris bandage 6 to 7 layers thick and 3/4 the length
of the knee circumference (from the medial to the lateral Hamstring tendon).
Remove the elastic bandage from the cast. Roll it up to keep it ready for the next step.
-Spread grease or vaseline over the proximal edge of the cast that is going to be
covered by the slab (approximately 3 cm high).
2/ Wet the slab and squeeze out the excess moisture. Lay the slab over the stump
proximal to the cast already there, overlapping the proximal 3 centimetres of the
initial wrapping.
3/ The patella should be positioned in the middle of the slab. The slab should then
be laid carefully down either sides of the knee and smoothed into the SC area. Care
should be given to moulding the plaster proximal to the patella.
-Pull a stockinet over. Wrap with the elastic bandage
4/ As the plaster begins to set, the fingers should be positioned on the SC area to
compress the soft tissue and accurately define the patella and the femoral condyles.
On the medial side, press as well posteriorly with the fifth finger as anteriorly with
the second finger. All four fingers should be arch like a crescent, right over the
medial femoral condyle. Laterally, the second and third fingers are anterior to the
tendon of the Tensor of the Fascia Latae. The fourth and fifth fingers should be
posterior to it.
Both thumbs rest in the PTB preset depressions.
5/ When the cast has set, remove the elastic bandage, then make some reference
marks at the intersection of the first part of the cast and the slab. Also you can record
the dimensions of the SC section with a callipers. Finally, draw a vertical line on the
front of the cast, through the centre of the patella, to indicate any so-called valgum
or varum of the amputees side.
Unfasten the clamps holding the elastic strap.
Remove the upper section of the cast. Then with the help of the patient, asking him
to flex lightly his knee, remove the lower section of the cast.
Using the reference marks and the calliper, reset the cast to its original dimension
and shape. If need so, make some required corrections on the negative mould. Then,
close the postero-proximal open section with three or four layers of plaster bandage
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With the cast removed and corrected we are now ready to fill and continue on to Cast
Modification.
Before filling the cast, it is helpful to place it in the sandbox so that the plumb line
is vertical and the cast is in five to seven degrees of knee flexion. In this way, when
the plaster positive is poured and the negative wrap removed, the mandrel will take
the place of the plumb line as a reference. This will be extremely important later
when you will be modifying the cast. It will help you to see the cast in the proper
alignment, and to make the modifications at their proper location. .
When the plaster has hardened and cooled, the wrap is cut posteriorly in the centre
to avoid damage to the positive in critical areas marked with indelible ink. The
indelible markings will have transferred from the stockinette to the plaster negative
and then to the plaster positive, and will act as a guide in the modification procedure
(see Fig. 4.15). Remember that it is possible for the marks to have moved. With your
finger, palpate the cast to identify the bony areas. Remark the reference points if
need to.
Fig.4.14
Fi n g ers
p o s i ti o n
SC S P
Se ct i o n
B as i c
c ast
A N T ER I O R M E D I A L
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Fig.4.15
49
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Another approach, which is very useful when casting a very big stump is the
following shown below. First you do stand on the side of the amputee instead of
being in front of him.
The medial tibial flare is moulded and emphasized with one hand, while the other
hand moulds the lateral wall between the head and distal end of the fibula. Finally,
the thumb and index finger of the one hand are spread as wide apart as possible and
the web space is used to firmly mould and compress the patellar tendon.
Counterforce is applied posteriorly with the palm of the other hand, so that the area
immediately posterior to the patella is flattened. This technique is shown in Figure
4.16. The triangular shape is thus maintained and enhanced, allowing controlled
channels for the medial and lateral hamstrings and the head of the fibula (see Figure
4.17 ). Care must be taken to maintain contact between the stump and the cast for the
medial and lateral condyles.
Particular attention should be paid to not compress the hamstring tendon in the
posterior area and to keep this same hand, parallel to the frontal plane of the stump.
Fig.4.16
Fig.4.17
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Another approach for taking a BK cast is standing up.
Fig.4.18
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SECTION - 5
CAST MODIFICATION
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CAST MODIFICATION
No matter how skilfully the mould was taken, further modifications are always
necessary. The object of these modifications is to increase socket contact pressures
in weight bearing areas and decrease contact pressures in pressure sensitive areas.
Wherever greater weight bearing pressures are desired, plaster is removed from the
positive, and where relief is desired, the cast is built up with plaster.
It must be understood and constantly borne in mind that every square centimetre of
stump surface available for loading should be utilized, however small it seems. For
this reason, over-buildup must be avoided. Over-buildup will negate the bridging
effect created around that area and will often result in an unstable socket. Total
contact will be lost, shear forces between the stump and socket will be increased, and
oedema pockets will be created.
Excessive undercutting of the cast in areas traditionally thought of as good weight
bearing areas can also have ill effects. One must not forget that between the socket
and strong, firm patellar tendon, for example, there is skin. Pressure sensitive areas
may be in contact with the socket surface during loading as long as weight-bearing
or pressure is avoided.
The following description of the cast modification technique can only be used as a
guide owing to the highly individual nature of the patients and their conditions.
Tools and other requirements:
1) Indelible pencil;
2) Knife, approximately 15 cm with narrow and flexible blade;
3) Scarpas knife;
4) Surform rasp blade (flat, half round and round);
5) Wire screen;
6) Spatulas;
7) 1/2 tacks with hammer or stapler;
8) Plaster container.
The positive cast is held in the vice by the mandrel. Before starting the
modifications, remove all the excess plaster, ridges and unnatural bumps, and shape
the proximal edge of the lateral and the medial supracondylar wall. All transferred
indelible ink marks should be darkened if necessary. Using both finger and eyes, try
to see if your references marks have not moved during the casting process. If they did
move, redraw them to the appropriate area.
It is extremely important for you to be viewing the cast in the proper alignment
during the modification process.
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The posterior trim line is defined by taking a line perpendicular to the mandrel (i.e.
parallel to the floor) from the mid-patellar tendon shelf straight across to the
posterior wall. It must be kept in mind that the cast is in 5 - 7 degrees of knee flexion
with respect to the mandrel. It is important to keep the posterior wall as high as
possible, especially with a shorter stump. However, there is also the amputees
comfort to consider; bulging of tissue when the amputee is seated is undesirable and
can be avoided.
Note: if necessary, the medial corner of the posterior brim may be slightly lowered
for the more prominent hamstring.
Then record all the measurements, diameters and circumferences, of the cast. Com-
paring your measurements, it should help you to judge and make the appropriate
modifications. Compare the cast measurements with the stump measurements. This
should help you to determine the intensity of your modification. It is part of the
prosthesis conception. The modifications is not something you do automatically,
all alike for every cast. Every patient is individual and requires a custom made
socket.
Using the midline and the reference
marks, use your template to see if the
form of your cast coincides with the
form of the stump. During the whole
modification process, you can refer to
your template in order to check if you
are not moving too far away from the
initial shape.
Starting with the M-L at the femoral
condyle, rectify the cast to bring it to
your initial M-L measurement. Remove
some plaster as well on the lateral side
as on the medial side. Notice that for a
well taken cast, the difference between
those two M-L shouldnt be bigger than
3 mm. If the cast is more than 3 mm
wider than the measurements, given
your measurements were well taken, the
cast was poorly done. If the cast M-L
is smaller, it is possible your measure-
ments were taken too loosely.
Please when correcting the M-L, respect the shape of the femoral condyles. There
shouldnt be flat or concave surface on the cast in those areas. Firm contact in this
area is essential to aid in mediolateral stability.
Fig.5.1
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Then we move unto the supracondylar area. Use an external calliper to measure the
M-L for that area. After comparing the measurements, you may find you have to
remove up to 2 cm of plaster. Start digging on the medial side with a curve knife
(Scarpa knife). Because of the morphology of that area, it can be well indented in a
crescent-like form. This way you are creating the space to later mould a thick wedge,
which will serve for the suspension of the prosthesis. When removing the plaster,
respect the form of the femoral condyle, staying as close as possible to the condyle
without touching it. Always make a nice flaring out proximally.
Laterally, on the opposite side, you can remove few mm of plaster with a semi
round Surform blade. You can slightly dig in. The tendon for the Tensor of the
Fascia Lata can be compressed on a large surface but not on a narrow one. Remem-
ber it is a counter pressure to assist the suspension of the wedge on the medial side.
Because there is often a large tissue mass just above the femoral condyles, when a
P.T.S socket is used, care must be taken to ensure supportive contact without im-
pinging on that tissue. Therefore, the proximal edge of a P.T.S socket must be flared
out gradually. After which you can start the regular modifications as for any PTB
socket.
Anterior Surface of the Cast.
The patellar tendon area is modified between the lower border of the patella and the
tibial tubercle to a depth of 5 to 10 mm. The depth of the shelf will depend on how
well the cast was moulded when it was applied to the stump, the AP diameter
measurement taken, condition of the skin, and the shape of the tendon, whether with
round edges or square ones. As for the width of the PTB, it can be up to 2.5 cm. If
you are using a soft insert rather than a hard socket, it can even be slightly wider.
It was believed you had to build up right under the PTB indentation. It has been
proven that there is a gap inside the socket even without building up that area.
Therefore, to improve stability, you should remove some plaster from that area,
down to the proeminence of the tibial tubercle. You just follow the shape of the tibia
in that area. Just make sure you always maintain a convex shape. Avoid any concave
sculpting in that area. The cutaway should gradually flare into the relief areas. Only
when this area is extremely sensitive (bursitis or else), you do have to avoid
removing plaster. Exceptionally, in few extreme cases, you may have to add some
plaster on the cast.
It was also believed that you do not remove plaster from the patella. Experience
show that in most cases you can remove few millimetres, up to 6 mm, on the lower
part of the patella. This does prevent to have the usual gap between the socket and
the stump in that area, therefore improving the cosmetic of the prostheses.
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Fig.5.2
56
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Fig.5.3
57
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The antero-medial surface of the tibia is then modified to within 1 cm of the crest of
the tibia. Beginning from the medial tibial flare to within 2 cm of the distal aspect of
the tibia, the cast is cut away to a depth of approximately 3 - 5 mm, depending again
on how the plaster wrap was moulded.
The anteriolateral aspect of the cast is modified, along the lateral border of the tibia,
close but not touching the crest, between the anterior lateral prominence of the tibial
plateau and to within 2 cm of the most distal aspect of the tibia to a depth 5 - 8 mm.
Avoid sharp concave digging. It is too uncomfortable and often painful for the
amputee.
Medial Aspect
The flare of the medial tibial condyle is a very important weight bearing area. It must
be kept in mind that with a soft insert, the medial flare will be compressing the soft
material during weight bearing. Therefore, when using a soft insert, you can be more
aggressive in the removing of plaster for that area. Please, maintain the contour of
the tibial flare. Locate the template (Fig. 5.4 ) at the medial midline of the model
using the indication marks as a reference. Depending on how much soft tissue there
is on the individual stump, and on how well the negative plaster was moulded, 3 - 7
mm of plaster is removed from the flare.
The M-L measurement (Fig.5.6, medial tibial flare to just superior to the head of the
fibula) should be used as a reference. The reduced area should be blended in
smoothly with the antero-medial surface.
Fig.5.5 Fig.5.4 Fig. 5.6
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Lateral Aspect
To ensure good counterpressure for the medial tibial flare, there must be definite
contact pressure at the stump-socket interface of the lateral wall. It is necessary to
maintain mediolateral stability during loading. In most cases, however, the lateral
wall of the amputees stump is far from ideal for this purpose, owing to the presence
of the head and distal cut end of the fibula. Extreme care must be taken not to
impinge on these areas. The shaft of the fibula is the only suitable area to use for
providing the necessary stabilizing counterpressure. Approximately 3 - 9 mm of
plaster may be removed from the cast between the head and distal end of the fibula.
Since a certain amount of sinking into the socket will take place during gait, care
must be taken to provide sufficient relief for the head of the fibula. Modification
should start approximately 2 cm distal to the fibular head and end about 1.5 cm
proximal to the cut end of the fibula.
Once again, the shorter the amputees stump, the less area is available on the lateral
wall to achieve mediolateral stability. To avoid a higher concentration of pressure
that is desired, the P.T.S type socket can be an adequate solution. An excellent way
to improve the medio-latera1 stability of the socket.
Posterior Aspect
The posterior surface of the amputees stump is the only area without any bony
prominences, and here plaster can be removed to reduce the circumferential
measurements. However, the hamstring areas must not be cut away, nor should the
distal posterior region of the cast. Any reduction of the latter area could cause
pulling of the tissue over the distal end of the amputees stump. Over-reduction of
the distal posterior region of the cast is often the cause of skin breakdown at the distal
anterior aspect of the tibia.
The popliteal area is reduced until the measurement corresponds to the AP diameter
taken previously. You can even remove few extra mm, up to 3 mm, to compensate
for the compressibility of the soft insert. The deepest part of the popliteal
counterpressure should be at the level of the PTB. Avoid making a walnut shape
bulge. The best result, for comfort and correct pressure distribution is when the
gastrocnemius depression is not deeper than 6 mm. Favourable loading areas should
gradually blend in with relief areas, so that sudden build-ups and reductions are
avoided.
59
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The cast can now be smoothed off with wire screen in those areas which have been
reduced. With a steel brush, rough the areas where you will be adding plaster. Run
water over the cast before adding plaster.
It is helpful to drive tacks or staples into the centre of each relief area so that the
length of tack left exposed is equal to the amount of relief desired.
The buildup for the flared posterior brim is best constructed by driving several tacks
halfway into the cast along the predetermined posterior brim line. A large quantity
of thick plaster mix is placed just superior to the brim line. Holding a tongue
depressor horizontally at the posterior shelf level, the plaster is scooped downward
in a short radius-curve with the long edge of the tongue depressor. This flare is then
blended in with the medial and lateral walls. This flare will serve to prevent tissue
bunching during knee flexion and will allow flexion to occur with reasonable
comfort.
Fig.5.7
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Modify sensitive area build-ups.
As a rule, 2 to 3 mm is sufficient, with the
exception of the most distal anterior aspect
of the tibia and perhaps the head of the fibula
Fibula head.
Add plaster build up, 3-5 mm thick over apex
and at least 6 mm distal to the lower border of
the head of the fibula. Also extend the apex
of the buildup posterior to the true
anatomical apex.
Anterior distal tibia
Add plaster buildup 5 mm thick over the
most prominent area. Extend the buildup
over the lateral border of the distal end of the
tibia. It is also wise to build up the distal end
of the tibia, 0.3 to 0.7 cm, depending on the
amount of total contact possible with the
individual amputee.
If the fibula is longer than the tibia, and protrudes beyond the main body of the
stump, add 6 mm of plaster over the area which protrudes.
Over buildup must be avoided, and any buildup that is applied should be blended
gradually into the other areas. Keep in mind that a mould that is properly trimmed
around pressure-sensitive areas will in fact create relief pockets without losing firm
contact and socket stability.
Total contact is of utmost importance, as it provides containment of the tissue,
feedback and improved circulation, and, generally, increases the surface area of the
stump-socket interface. Care must be taken to prevent excess buildup distally in
order to ensure a total contact fit. While total contact is important, it should not be
mistaken for end bearing. With the wire screen give the cast a smooth finish.
The model is ready for use in fabrication of the socket.
Fig.5.8
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REFERENCES
1. Below Knee Prosthetics, Course Work Manual, National School of Prosthetics &
Orthotics, Phnom Penh, Cambodia.Carson Harte, Anne Henriksen.
2. Clinical Aspects of Lower Extremity Prosthetics, Trans-tibial, Symes and Partial
Foot Amputations, The Canadian Association of Prosthetists and Orthotists.
3. Trait dAnatomie Artistique, Dr. Paul Richer, Inter-Livres
Compiled and edited by Jacques Forget, CCP (Canadian Certified Prosthetist).
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