Case Report Student’s name: LEAP VANNO Device: TF (Left) Quadrilateral Socket Patient’s name: TENG SOKLY Date of casting/Assessment Date of fitting 20/June/2013 05/July/2013 Patient’s History My client’s name isTeng Sokly, male and 34 years old. He has left sided Trans-femoral amputee because traffic accident in 2006. He is married and has 2 children, one son and one daughter. He lives in Svay Rolum Village, Svay Rolum Commune, Shrang Distict, and Kandal Province with his family. He lives in the first floor of the house which has steps and he can used and helpful for him when he goes up and down, but usually he stays in ground floor .Bathroom/toilet is near his house. Around his house is even ground and there is muddy and floating during rainy season. He is a motor repairer. He sometimes works as a motor dub. He uses the prosthesis for performing his daily activities and carries heavy thing (machine) except during sleeping. He does not like playing any sport, he like play snooker in his free time, he helps his wife housework like cooking and take care his children. He is a secondary patient. He has used 6 prostheses. All sockets are difference Socket ,4 Quadrilateral ,and 2 IRC socket made from Cambodia Trust. The first prosthesis was Quadrilateral Socket that made in 2007. His previous socket was made in 2011 that made from 5 mm polypropylene with Silesian belt, ICRC single axis knee manual knee lock, endoskeleton shank, SACH foot and the soft cosmesis cover outside. His socket was too loose. He used 2 stump socks. Assessment During assessment I found that his general health is good with upper and eyesight are normal. His amputee side and sound side are full ROM with muscle strength grade 5 as tested with Oxford muscle scale. He has good sensation and proprioception, normal muscle tone, no muscle atrophy, no have spin deformity .For the right side of lower limb at the hip joint, knee joint, and ankle joint are full of ROM with muscle strength grade 5. His stump is short stump, conical shape, soft tissue, sutures and anterior bony prominent bone at distal end. He has sweat skin rash at the medial of the stump and discoloration at the lateral distal of the stump because he used 2 stump socks . Previous Device o Instable of the knee o Socket to much external rotation o Socket is too loose because he used 2 stump socks. Functional lost He cannot walk and perform his work independent because he had lost left transfemural amputee. Main complain He comes to clinic because his prosthesis is too loose. He used 2 stump socks and instable of the knee. The cosmesis cover outside is damage and SACH foot is corrosion. Prosthesis Goals: o Replace the missing function of the knee ,foot and tibia o Allow distribution of weight on both legs during standing and walking. o Provides a good suspension so that he can do activities securely o Provide good fit for weight distribution o Save energy o Make the prosthesis that looks like a real sound side Prescription: Base on my subjective and objective assessment, I would like to prescribe for him is a Quadrilateral socket, with Silesian belt for suspension, ICRC single axis knee joint manual knee lock (which can be locked), Endoskeleton shank, SACH foot soft cosmesis. The reason I prescript this because: Quadrilateral socket: o My client used this kind of prosthesis long time. o Most commonly used socket for Transfemoral amputees o Providing total contact for good blood circulation o To control rotation of stump inside the socket o And provide the major weight bearing on the ischial seat. Socket Material: 5mm Polypropylene o Locally available o Lightweight o Strong o Durable o Cheap o Adjustment can be done by heating o Water resistance o Can recycle Silesian belt: o Secure comfortable o Does not restricts movement o Improve M-L Stability and rotational control. Knee joint –single axis (ICRC) manual knee lock: o Made with a simple single mechanism o Strong enough o Low cost than multi axis knee joint o And easy to repair Stance phase control – manual knee lock But in this case, the patient unlocks the knee lock and uses his muscles to control knee stability because he has strong firm muscles o He can try to use the knee lock for maximum stability throughout stance phase Swing phase control – friction control o Low weight o Simple design which has low maintenance o No external extension aid to use Endoskeleton shank: o Easy to adjust alignment o Strong o And good cosmesis. SACH foot (size 25): o Provide shock absorption during heel strike and rigid lever arm at the end of stand phase o Durable o Easy to clean o Can use in any environment and condition Cosmesis – soft Cosmesis o Make the prosthesis look good(more cosmetic) Other option: If the material is available for manufacture, I would like to prescribe: Quadrilateral socket that make from lamination because it’s more strong and lightweight. Knee joint (Polycentric ) because easy to clear the ground during swing phase . Foot and Shank(SACH foot and Endoskeleton shank ) because it is suitable for my client as he work as repairer the electrical tools that need standing, sitting, and walking during he was working .Also, I make the socket with soft cosmesis for him because it is suitable for his living and working condition and look like real. Silesian belt suspension because provide secure during he is working. Soft cosmesis because look like real to compare to sound side. Casting, Rectification and fabrication Before I casting, I mark at ischial tuberosity, adductor tendon, greater trochanter, distal of femur bone and mark 5cm, 10cm, below Ischial tuberosity. Then I measure the circumference at level ischial seat, below ischial seat 5cm, 10cm . And then I measured at adductor tendon (A-P diameter), M-L diameter, and length of foot at sound side, length from ischial tuberosity to the floor, length from medial tibia plato of sound side to the floor. I casted my patient twice time. My first cast the shape not look like quadrilateral and ischial seat is not correct so I casted again. The second cast looks better than the first. I cast my patient in standing position. I stand at the lateral side of my patient amputee and the position of my right hand is under the ischial tuberosity and other hand is on the anterior wall pressure for femoral triangle and assistant hand is on the media side at the groin area which is 90 degree to my posterior hand and parallel to the line of progression and other hand at the lateral wall to keep femur adduction position. During Rectification, I follow the procedure of rectification. Then I follow the bench alignment procedure .During static alignment: o Check the stump before I let the patient to put on the stump sock and socket. o Check the Ischial Tuberosity is on the Ischial seat or not o Check adductor longus tendon in correct place or not o Check the proximal of the socket is it fit or not o The trim line is medial wall, lateral wall, posterior wall and anteriorare too short or too long and smooth or not. o Check the anterior trim line that is not pinging when he bend the trunk forward or flex during sitting o Check the high of the prosthesis. o Check the foot is flat to the floor or not. o Check for the knee and foot stability. o Check is suspension well. Fitting and Outcome Static alignment The inter face liner was not good fitted with patient’s stump. Ischial tuberosity is incorrect place. Ischial tuberosity falls inside socket so I correct by pad EVA at the scarpa triangle. The height of prosthesis side was shorter than sound side 4mm between knee axis to the foot that checked by feel at ASIS, PSIS, Iliac crest and shoulder. Then I added the 4mm of polypropylene. The lateral wall has gap so pad EVA at lateral side. Also, my socket was a little bit tight at distal end of the stump. I correct it by heat the socket outside at that area. Finally, my client can wear the prosthesis. Dynamic alignment My socket was too much abduction so I reduced abduction by tilt socket to adduction. Foot is too much external. I correct by rotate the socket to external. Gait Deviation Gait deviation with old prosthesis Reason for gait deviation Gait deviation with new prosthesis Reason for gait deviation Medial whip Patient secure(habit) Abducted gait Socket too much adduction Lateral trunk bending Socket short Lateral trunk bending Socket short Instable of knee Socket flexion quietly Foot rotation at the heel strike Knee internal rotation In this project, I have learned about bench alignment for TF and how find attachment point of Silesian belt. The bench alignment Describe the bench alignment for TF prosthesis Sagittal plane: Socket angle: o Socket 15 degree flexion (to prestretch hip extensor to help control knee stability at heel strike the most unstable phase for transfemoral). Coronal plane o Socket adduction 5 degree adduction (follow the anatomical position). The seat and medial wall should be horizontal when the socket is in the correct angle. Posterior and medial should be horizontal and parallel to the line of progression. Plumb line : o Coronal plane : -Posterior plumb line: The plumb line should fall middle of posterior socket wall through to the mid of the heel. o Sagittal plane: -Lateral plumb line - should fall through mid line of socket to 1/3 of foot from mid of the heel. TKA line : o Sagittal plane: The vertical line fall from the TKA line passes 1.5 cm to 2cm anterior to the knee joint and one –third of the foot. Foot o Foot set 5 degree external rotation. Transverse plane: The knee joint it should place in 5 degree external rotation. How find attachment point of Silesian belt: o Anterior of the socket: Level of ischial seat and mid of the socket o Lateral of the socket • Find apex of greater trochanter • And move 0.5mm to superior and 0.5mm to posterior
Posted on: Thu, 04 Jul 2013 13:31:13 +0000
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