Prosthetic Fitting and Training

Pre-Prosthetic Management - Stump Smart Start

• Patient Assessment (Holistic):
  • Medical status (comorbidities like DM, PVD).
  • Functional goals (ADLs, mobility).
  • Psychological readiness (coping, body image).
  • Vocational needs (return to work).
• Stump Assessment (Thorough):
  • Length & Shape: Aim for conical/cylindrical.
  • Skin: Integrity, scars, infection signs, sensation (neuroma).
  • Joints: Range of Motion (ROM), Muscle Power (MMT).
• Stump Care & Conditioning (Key to Success):
  • Edema Control: Figure-of-eight elastic bandaging, shrinker socks.
  • Shaping: Achieve mature stump for prosthetic interface.
  • Desensitization: Tapping, massage, texture exposure.
  • Hygiene: Daily cleaning and skin inspection.
  • Exercises: Strengthening (proximal muscles), ROM.

⭐ Stump volume fluctuation is greatest in the initial 3-6 months post-op; consistent compression is vital for optimal prosthetic fitting and to prevent stump edema related complications such as pain and skin breakdown.

Prosthetic Components & Prescription - Limb Lego Logic

• Principles: Maximize function, comfort, cosmesis; match patient's activity level & goals.
• Core Components:
  • Socket: Critical interface with residual limb. Key types:
    • Transtibial: Patellar Tendon Bearing (PTB), Total Surface Bearing (TSB).
    • Transfemoral: Quadrilateral, Ischial Containment.
  • Suspension: Secures prosthesis (e.g., suction, pin/lock, vacuum, straps).
  • Joints: Knee units (single-axis, polycentric, microprocessor-controlled), Ankle-foot assemblies (e.g., SACH, dynamic response/energy-storing feet).
  • Terminal Device (UL): Hooks (functional, durable), Hands (cosmetic, functional - e.g., myoelectric).
• Prosthesis Types (Examples):
  • Upper Limb: Body-powered (harness & cable), Myoelectric (EMG signals).
• Materials: Lightweight, strong, durable: Carbon fiber, titanium, aluminum alloys, thermoplastics.

⭐ The SACH (Solid Ankle Cushion Heel) foot is a basic, non-articulated, durable, and widely prescribed prosthetic foot, especially suitable for initial fittings and lower activity users due to its simplicity and stability during early stance phase of gait.

Prosthetic Fitting & Alignment - Socket Fit Feats

• Socket Casting & Fabrication:
  • Transtibial (TT): Patellar Tendon Bearing (PTB) socket.
    • Key landmarks: patellar tendon, medial tibial flare.
    • Pressure tolerant: patellar tendon, medial/lateral flares.
    • Pressure sensitive: fibular head, tibial crest, distal tibia.
  • Transfemoral (TF): Ischial Containment (IC) socket. Encloses ischial tuberosity & pubic ramus for stability.
• Alignment Principles:
  • Static (Bench): Initial setup. LL: Plumb line from greater trochanter to mid-heel.
  • Dynamic: Gait observation. Adjust for comfort, function, energy efficiency.
• Prosthetic Checkout:
  • Sequence: Bench → Static (standing) → Dynamic (walking).
  • Criteria: Comfort, stability, no pistoning, good skin integrity post-use.
• Common Fit Issues & Adjustments:
  • Pressure areas (modify socket), pistoning (improve suspension), bell-clapping (add distal padding), rotation (check alignment/suspension).

⭐ For PTB sockets, approximately 60% of weight is borne by the patellar tendon bar, with additional support from tibial flares.

Prosthetic Training & Rehabilitation - Gait & Grip Glory

• Goals: Maximize functional independence, safety, QoL with prosthesis.

• Lower Limb (LL) Training:

  • Donning/doffing independently.
  • Balance, weight transfer, proprioception.
  • Gait phases: Parallel bars → walker/crutches → cane → independent ambulation.
  • Obstacles: Stairs (step-to/step-over), ramps, uneven surfaces.

• Common LL Gait Deviations & Corrections:

  Deviation	Cause(s)	Correction(s)
  Abducted Gait	Prosthesis long; hip contracture	Length; stretch; training
  Vaulting	Prosthesis long; ↓ knee flex	Length; ↑ knee motion; training
  Circumduction	Prosthesis long; ↓ knee flex; fear	Length; ↑ knee flex; confidence

• Upper Limb (UL) Training:

  • Donning/doffing.
  • Controls: Body-powered (harness), Myoelectric (EMG).
  • Functional use: ADLs, vocational tasks.

• Patient Education:

  • Wear schedule: Gradual increase to prevent skin issues.
  • Skin care: Daily inspection, hygiene, sock management.
  • Prosthesis care & maintenance.

⭐ Phantom limb sensation (non-painful) is common; phantom pain needs active management.

High‑Yield Points - ⚡ Biggest Takeaways

• Pre-prosthetic care focuses on stump maturation, muscle strengthening, and contracture prevention.
• Socket design (e.g., Patellar Tendon Bearing (PTB), Ischial Containment) is critical for optimal fit and function.
• Correct static and dynamic alignment is crucial for an efficient gait pattern and stability.
• Gait training progresses through balance, weight transfer, and ambulation practice with the prosthesis.
• Differentiate phantom limb pain (neuropathic origin) from residual limb pain (often mechanical or ischemic).
• Signs of poor prosthetic fit include pistoning (vertical movement) or socket rotation.
• Successful prosthetic rehabilitation requires a coordinated multidisciplinary team approach including the patient an prosthetist