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.extremityjoint To restrict movement in a given direction To assist movement generally To reduce weight bearing forces for a particular purposeweight bearing 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. traumasurgerymalignancygangrene

Trauma :  RTA(Road Traffic accident)/ train accident.  Industrial accident.  Fracture complications.  Burns ــ thermal, 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 Patient Surgeon Physical Therapist Prosthetist Psychologist Occupational Therapist Ergonomist

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 re- amputation. 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