Category Archives: Kaki Palsu dan alat Medis

How the prosthesis for Transtibial amputees with short stumps might be improved?

How the prosthesis for Transtibial amputees with short stumps might be improved?
By Nur Rachmat

Introduction
Short stump of Transtibial amputee is one of the difficulties of the Prosthetic management. Many complications such as short lever arm abducted and hyper extended stump which might be accompanied with mediolateral instability challenging Prosthetist to improve the Prosthetic treatment, to achieve better result for the patient. Several Factors such as pressure distribution, socket design, suspension, and Alignment of the Transtibial Prosthesis are to be considered.

Short stump of Transtibial amputee
Transtibial stump which less the 12 cm in length is considered as short stump, or the amputation which is done on proximal 1/3rd of tibia. Short stump having many characteristics, such as:

Abducted Stump. The stump is abducted which due to the strong iliotibial band which stretch the stump in abduction. Iliotibial band is inserted to the lateral condyle of tibia.

Hyper extended Stump. The reason is due to the strong knee extensor muscle (Quadriceps muscle), which unopposed by the knee flexor muscle. The Gastrocnemius which serve as a flexor of knee joint had been cut during amputation. Due to lost of this muscle power, the knee tends to be hyper extended.

Mediolateral instability of knee joint. Short stump may have mild mediolateral instability which possibly due to laxity or rupture of collateral ligaments. Short stump will have to bear more force which comes from body weight; it is due to less area of pressure distribution. More force coming to knee joint which leads to ligament fatigue, then laxity or ruptured of these ligaments may occur and medial lateral stability of knee joint will be disturbed.

Short lever Arm. Due to the length of the Tibia which is too short, the lever arm for the stump to bring about movement of the prosthesis is also less. Less lever arm will have to bear more force coming from body weight during stance, need more energy or muscle activity to raise the prosthesis during swing phase.

Less area for Pressure Distribution. Normally, in socket, more pressures are to be bear by Pressure tolerance area, and less forces are to be born by Pressure sensitive area. Less area on short stump limiting for pressure distribution, as more Pressure tolerance area, that is bulk of muscle on medial and lateral Tibial flare have been cut. Bony areas which are pressure sensitive area left in residual limb, which leads in difficulty in pressure distribution.

Figure No.1. Show bilateral Transtibial amputee. Note that both of the stumps are very short. Left stump is more abducted. Figure adopted from http://www.dinf.ne.jp/doc/english/intl/z15/z15001p1/z15001g/z1500104g01.jpg

Improvement in Transtibial Prosthesis

Several ways can be done to improve Transtibial prosthesis for short stump. The idea is to understand the characteristic of the short stump, and to accommodate those characteristic in the prosthesis. The deviation present in the stump can not be corrected in the prosthesis, which means, prosthesis should follow the stump shape. The improvement on the prosthesis can be done by means of alignment, socket design, suspension, and selection of prosthetic component

Prosthesis Alignment. Short stump usually abducted and hyper extended. In frontal view, Socket is to be aligned in abduction to follow the stump deviation. But the shank should be vertical. By this alignment, amputee will stand comfortably on static alignment, with the shank and foot located symmetrically as the sound leg. It is also prevent from medial or lateral trust gait deviation. In sagital view, the socket is to be aligned in more flexion, that is up to 150 flexion. Increase flexion will prevent the knee hyperextension.

Suspension. Selection of suspension is also critical important. Supra-Condylar Suspension is preferable if the patient having good mediolateral stability. Good suspension because of the contour of femoral condyle as well as easy donning and doffing makes this suspension preferable. Pressure above the Patella is needed to prevent hyperextension. If mediolateral instability present, thigh corset can be use for suspension, as mechanical knee joint will be used to stabilize the knee.

Socket Design. Supra-condylar Supra-Patella (SCSP) design is best for short stump when mediolateral instability absent. SCSP trim lines are above femoral condyle for suspension and above patella for supra patella pressure, thus prevent hyperextension.

Figure No. 2. show PTB SC-SP Socket design.
Note the high trim lines above femoral condyle and patella. Figure adopted from: http://books.google.com.pk/books?id=FuuNnSsK8-4C&pg=PA87&lpg=PA87&dq=SCSP+socket&source=web&ots=1fY4Nm_bDO&sig=RdeOrgj3k52_k95BpJL14d17NSA&hl=en&sa=X&oi=book_result&resnum=4&ct=result#PPA87,M1

Prosthetic Component. Weight of the prosthesis is also in critical important. Short stump will not able to carry more weight. There for selection of light in weight but strong component is important. Component made form titanium, which is prefabricated by ottobock, ossur, endolite, proteor can be an option.

Conclusion
Transtibial short stump having characteristic of abducted and hyper extended, improvement on the prosthesis can be done by means of alignment, socket design, suspension, and selection of prosthetic component. Accommodate the shape of the stump what ever it is. Align the socket in same abduction angle in the stump and 150 flexion if hyperextension present in the stump. If flexion contracture present, accommodate that angle in the socket. PTB-SCSP and light in weight but strong material is preferable.

Reference:
1.Gonzalez E, Corcoran P, Reyes R. Energy expenditure in below knee amputation: correlation with stump length. Arch Phys Med Rehabil. 1974;55:111-119.
2.Murphy EE, Wilson AB Jr. Anatomical and psychological considerations in BK prosthesis. Artificial Limbs. 1962;6:4-15.
3.http://www.dinf.ne.jp/doc/english/intl/z15/z15001p1/z1500104.html
4.http://www.dinf.ne.jp/doc/english/intl/z15/z15001p1/z15001g/z1500104g01.jpg
5.http://www.ncbi.nlm.nih.gov/books/bv.fcgi?indexed=google&rid=physmedrehab.section.8475
6.http://osteosupportindonesia.blogspot.com
7.http://kakipalsu.co.nr

scoliosis patient, treat by Boston TLSO

Case Presentation on Scoliosis
Patient: Adina Fatima

Layout of the Presentation
*Subjective Assessment
*Objective Assessment
*Diagnosis
*Treatment Objectives
*Prescription & its Justification
*Education to the patient
*Conclusion

Subjective Assessment
Personal information
*Name : Adina Fatima
*Father N : Syed Wajid Ali Shah
*Address : Forest Colony Police st. Gul Bahar Peshawar city
*Contact No. : 03339162684
*Age : 6 Years
*Gender : Female
*Height : 76 cm
*Weight : 15 kg

Social condition

*Assistance available: parents
*Financial Condition: Poor
Past medical History: The patient was born normal. Her parent realize that she had the deformity at the age of 3 years, then they consult doctor, doctor refer her to PPCC for orthotic treatment. She has chest infection. Up till now she has used 1 Orthosis.
Present Complaint : Patient come for review of her appliance. Patient feel uncomfortable with the abdominal pressure in her previous appliance.

Objective Assessment
Observations:
*Posture: Left Lateral Curve
*Mental Status : The patient was well oriented at the time and space
*Position of Upper Limb: Right Side Down
*Pelvic Level: Normal (Level)
*Clearance test:
*Low squat test: negative
*Faber Test: negative
*Toe standing test: negative
*Back scratch test: negative
*Coordination test: negative

Objective Assessment cont.
Special Tests:
*List Test : negative
*Adam’s Test: positive, Hump at the Left side
*Lateral bending test: flexible curve, the curve reduce when the patient tilt toward convexity.


Radiological examination (X-Ray)
Apical Vertebrae: T10.
Upper End Vertebra T7
Lower End Vertebra L1
Cobb’s Angle: 15°
Single curve thoraco lumbar (C shape)
Diagnosis
Scoliosis
Detail of Diagnosis:
Left lateral thoraco lumbar Single curve (C shape)
Apical Vertebrae: T10.
Upper End Vertebra T7
Lower End Vertebra L1
Cobb’s Angle: 15°
Cause of Deformity: Idiopathic

Treatment objectives
*Prevent the progression of deformity
*Reduce the magnitude of curvature
*Improve Cosmesis

Prescription

Thoraco Lumbo Sacral Orthosis (TLSO)
(Low Profile Orthosis)
Detail of Prescription:
*Boston Design
*Three Point Pressure System
*Anterior Opening
*Made out of Poly Propylene Sheet (4mm)
*Straps, made of Webbing Belts & Velcros (5cm)
*5mm Tape foam for Pressure pads at Axilla (right side) & diagonal direction of apical vertebra
*6mm Plastozote for Relief Pads on iliac crest
Justification of Prescription
*TLSO with Boston Design because apical vertebrae are below T8 and curve is C-shaped
Three point pressure system correction
* Primary pressure, medially directed force (from left side on diagonal direction of apical vertebra) toward apical vertebra
* two counter pressures;
1) below axilla
medially directed force
(from right toward left)
2) at the pelvis
medially directed force
(from right toward left)
*Anterior opening for easy donning & doffing, as well as good cosmesis
*Polypropylene Sheet(4mm)for appropriate pressures & strength.
*Webbing belts & Velcros for intimate fitting and holding
*Pressure pads for application of pressures on exact areas.
*Relief pads to avoid pain on bony prominences (iliac crest)

Education to the patient
*Patient is asked to:
*Use the appliance for 23 hours per day
*Come for review after 3 months an bring X-ray
*Exercises, those are: hanging and manual traction twice a day.

Conclusion
The patient is diagnosed having scoliosis deformity, and TLSO with Boston Design is prescribed. Patient & father are satisfied, patient is asked to come after o3 month, and bring the X-ray of patient (with & without appliance). to know effect of Orthosis and the alteration of the Cobb angle magnitude.

test klinis pada pasien sebelum mendapatkan protese atau ortose, bagian 1: sbjective assessment

pada artikel ini aku ingin membahas tentang cara melakukan assesment pada pasien, khususnya tentang bagaimana cara melakukan clearance test. apa sih clearance test itu? clearance test adalah test yang dilakukan pada pasien secara kesluruhan, untuk mengetahui kondisi umum (general condition) pasien. kenapa ini sangat perlu? ini akan mempermudah kita sebagai tenaga medis (orthotist, prosthetis, fisioterapis, dll) untuk mengetahui letak masalah yang ada pada pasien. bagaimana cara melakukannya?

saat pasien datang ke klinik kita, kita lihat cara pasien datang, ada beberapa pasien yang datang dengan pincang, ada yang datang dengan dibopong sanak keluarganya, atau ada yang datang dengan gaya jalan yang tidak normal. dengan melihat bagaimana cara pasien datang, kita mendapatkan sedikit gambaran tentang pasien, yang untuk selanjutnya kita mencari tau lebih banyak melalui percapakapan (objective assesment).
pada objective assesment, yang perlu kita ingat adalah kita harus sedapat mungkin mendapatkan informasi tentang pasien, dengan pertanyaan yang jawabannya tidak hanya ya atau tidak saja, tapi kita harus bisa betanya dengan pertanyaan yang jawabanya merupakan penjelasan dari pasien. contoh pertanyaan yg hanya jawabanya ya atau tidak (close ended question): apakah kaki anda sakit disebelah sini? tentu saja jawabanya ya atau tidak. pertanyaaan yang baik: dimana anda merasakan sakit? bisakah anda ceritakan tentang sakit yang anda rasakan?. nah, begitulah cara mendapatkan informasi dari pasien. kenapa sih kita harus mencari informasi tentang pasien secara menyeluruh? ya, tentu saja, agar kita bisa mendapatkan diagnosa yang tepat, dan selanjutnya, kita sebagai orthotist prosthetis bisa memberikan alat bantu yang tepat sesuai dengan diagnosis yang kita dapatkan.
kembali ke subjective assessment. disini yang kita tanyakan misalnya:
nama lengkap pasien, nama ayah / nama suami, alamat, nomer telefon yang bisa dihubungi, umur, berat, tinggi, pekerjaan, hobi, aktivitas, asistent, kondisi keuangan, keluhan yang dihadapi, cerita bagaimana penyakit ini datang, apa yang diinginkan pasien, dll. semua info itu sangat berguna, dan ditanyakan untuk beberapa alasan, misalnya, tentang nomor telfon, kita butuh nomer telfon karena suatu saat kita perlu menghubungi pasien jika ada informasi yang perlu diketahui oleh pasien. pertanyaan tentang aktivitas pasien, ini akan memberikan gambaran kepada kita seberapa aktif pasien kita, misalnya dia kehilangan kaki karena amputasi, yang kemudian dia bakal butuh kaki palsu, maka kita bisa memilihkan komponen yang sesuai dengan aktifitasnya. yaitu yang ringan dan kuat.
untuk selanjutnya kita lakukan objective assessment, yang akan aku bahas dipost yang akan datang.

kaki palsu untuk amputasi atas lutut

kesedihan terlintas di wajah Minhad Shah, seorang penjaga toko berumur 24 tahun ini, kehilangan kaki kanannya saat dia berumur 4 tahun. saat ia masih kecil, dia terpaksa harus kehilangan kaki kanan nya sebatas paha (transfemoral amputation) disebabkan terjadinya perselisihan antara keluarganya, yg mengakibatkan peluru dari pistol mendarat di kaki kanannya.
saat itu dia dibawa ke Lady Reading Hospital yang terletak di kota Peshawar, Pakistan. sejak saat dia tidak bisa beraktifitas layaknya anak-anak kecil lainnya. dia begitu sedih meratapi nasibnya. samapai pada suatu hari, ditahun 1992, dia mendapat kaki palsu (tansfemoral Prosthesis) dari Khyber Teaching hospital oleh donatur dari Jerman.

mulai saat itu, dia merasa mendapatkan kehidupannya kembali, dia bisa beraktifitas dan bermain2 bersama temen2 nya. tapi dia harus menghadapi kenyataan bahwa kaki palsu tersebut tidak bisa digunakan selamanya. Dengan bertambahnya umur, dia harus mengganti kaki palsunya, karena ukuran stump yang membesar, dan perkembangan tubuhnya.
untunglah PIPOS (Pakistan Institue of Prosthetic & Orthotic Sciences) berkenan menjadikan dia sebagai Pasien utk Latihan Mahasiswa2 PIPOS dalam pengajaran P&O. mulai saat itulah dia mendapatkan kaki palsu baru saat Module pembelajaran Transfemoral Prosthesis diadakan di PIPOS tiap tahunnya. alangkah sulit bagi dia utk membayar kaki palsu, karena keadaan ekonomi yang lemah.
Di tahun ini, dia datang ke PIPOS, saat Transfemoral Prosthesis Module dimulai, dia datang ke PIPOS dengan wajah yg sedih. “tolong bikinkan aku kaki palsu baru, karena kaki palsu ku yang lama sudah mulai tidak nyaman dipakai dan terlalu pendek” ujarnya. Sebagai mahasiswa PIPOS semester 6, aku pun mulai melakukaan Clinical Assessment, diagnose, dan Prescription. Lalu mulailah aku melakukan Pengegipan (casting), dan selanjutnya pembuatan kaki palsu tersebut. saat kaki palsu tersebut aku pasang ke stump nya, dia merasa nyaman, dan dia menyukainya. terlihat senyum diwajahnya. “terimakasih banyak” ujarnya. aku merasa bahagia bisa membantunya. sekarang dia bisa beraktifitas kembali dengan nyaman. (Nur Rachmat)

Minhad dengan kaki palsu barunya

minhad & aku

terlihat senyum diwajahnya.

produk kami, dengan menggunakan ICRC & ottobock component




transfemoral prosthesis & transtibial prosthesis produk kami




foto-foto prosthesis & orthosis produk PIPOS