CASE REPORT

TOTAL SOCKET BEARING TRANSTIBIAL PROSTHESIS

Aristyo Raja Leksono

(P17127019002)

Polytechnic of Health Science Jakarta I

Ministry of Health of Republic of Indonesia
Prosthetics and Orthotic Department
2019/2020
 TABLE OF CONTENT
SUBJECTIVE ASSESSMENT
OBJECTIVE ASSESSMENT
PRESCRIPTION
CASTING
RECTIFICATION
FABRICATION
SOCKET FITTING
PATIENT EDUCATION
SELF CRITIC
Unilateral Total Socket Bearing with Silicone liner + Pin/Lock system Transtibial Prosthesis
Right side.
Assessment Rectification Fabtication Socket
and Casting fitting
22nd Februari 23rd Februari 1st March 4th March
2021 2021 2021 2021

SUBJECTIVE ASSESSMENT
1. Patient Details
Patient Name: Agus Fitriadi
Preferred Name: Agus
Date of birth: -
Sex: Male
Phone Number: 08561341766
Address: Jl. Rawasari II Rt/Rw: 004/05 No. 36, Cipayung Jaya, Depok
Height:
Weight:
Employment: Athletes
2. Contact Details
Name: -
Address: -
Relationship: -
Phone Number: -
3. Family/Social Situation
Dependent: -
Caretakers: -
Education: Junior High School
Time Travel: 45 minutes – 1 hours
 4. Patient History
In 2000’s patient got a train accident that causes his foot is break. And he amputated on 2008’s.
The patient start using the prosthesis at 2015. After he got amputee at 2008 the patient do his
daily activity as a athelete by using wheelchair before he got his first prosthesis from JSPO. And
from 2015 until now he have 3 device, and he always take care his prosthesis.
5. Diagnosis
Unilateral transtibial amputation on the right side with short stump
6. Activity of Daily Living
Patient spent his time as an athlete, but when training he use a wheelchair. So, he have medium
activity
7. Previous Device
Medial Lateral Anterior

Posterior Transvers

8. Patient Problems
 Discoloration at the weight bearing part
 Redness at the suspension part
 OBJECTIVE ASSESSMENT
1. General Health Condition
 Patient in good health, not feeling pain nor sick
 Patient has no difficulty in communication
 Patient able to maintain balance during standing and walking in even and uneven
terrain, inside and outside the house
 Cooperative following and understanding the instructions
2. Upper Limb and Trunk Condition
Good hand Functions
3. Lower Limb Condition
 Has short stump
 Good sensation on the amputee (L) and sound side
 Good Proprioception
 Good muscle strength on both legs
 No ligament laxity
 No have contracture

4. ROM and Muscle Strength

ROM Muscle Strength
Knee Joint Active Active
R L R L
Flexion 125o 123o 5 5
Extension 10o 5o 5 5

Ankle Joint R L R L

Plantarflexion 5
Dorsiflexion 5
Inversion 5
Eversion 5
Proprioception Normal Normal
 Sensation Normal Normal

5. Special Test
 Valgus/Varus stress test on the amputee side, patient has no positive sign of that test, and
no excessive movement when medial/lateral directed force on the knee aplied.
 Valgus/Varus stress test on the sound leg , patient has no positive sign of that test, and no
excessive movement when medial/lateral directed force on the knee aplied.
 Anterior drawer test on the amputee side, patient has no positive sign of that test, and no
excessive movement occurs during the test.
 Anterior drawer test on the sound leg side, patient has no positive sign of that test, and no
excessive movement occurs during the test.
 Posterior drawer test on the amputee side, patient has no positive sign of that test, and no
excessive movement occurs during the test.
 Posterior drawer test on the sound leg side, patient has no positive sign of that test, and
no excessive movement occurs during the test.
 Sensation test on the amputee side, and it shows that the patient has a good sensation on
that side.
 Sensation test on the sound leg side, and it shows that the patient has a good sensation on
that side.
 Proprioception test on the amputee side, and it shows that the patient has a good
proprioception on that side.
 Proprioception test on the sound leg side, and it shows that the patient has a good
proprioception on that side.
6. Gait Observation
No Phase of Gait Left Leg Right Leg Trunk
(Hip, Knee, Ankle)) (Hip, Knee, Ankle)
1. Stance Phase Uneven timing Sound side Normal
Uneven step length
2. Swing Phase Uneven timing Sound side Normal

7. Prosthetic Goals
 Replace the missing part of the limb by prosthesis
 Provide comfortable prosthesis
 Provide standing and balance by make the prosthesis same level with sound side
 Improve gait pattern compare with previous device
 Supporting activity daily living as an athlete
 Improve quality of life by achieve all of the goals

Real Prescription
 Name Design/type/material Reason
Interface liner Silicone Gel Liner  Provide total contact
 Good suspension
Socket material Thermophylline 12mm  Provide strong material
 Easy to clean
 Material availability
Socket Design TSB socket  Provide Comfortable
 Good circulation and less
edema
 Better for proprioception
Weight bearing All of the surface of the stump  All of the surface of the stump
area for weight bearing in PTB
socket
Suspension Silicone Gel Liner Pin Liner +  Available in different softness,
Lock features and activity levels
 Many choice for locking
mechanism

Casting
1.Prepare all the tools needed:
-Measurement chart - marker
-Ruler -Indelible pencil
-POP bandages(15 cm wide) -Goniometer
-Plastic wrap -A basin of water
-Plumb line - Heavy duty scissor
-Surgical scissor - Casting chair
-Calliper - Adjustable Knife
- Tape measure -Towel

2. ask permission to the patient and explain the procedure.

3. help the patient to wear silicon liner, make sure the umbrella is in the middle of distal end

4. cover the patient stump using plastic wrap. Make sure there are no wrinkle area from the
plastic

5. mark the measurement using marker at :

●Patella ●Medial and Lateral Tubercle of Tibia

●Patella Tendon Bearing (PTB) ●End of tibia and fibula

●Tibia Tubercle ●Head of Fibula

●Adductor tubercle ●Medial and Lateral Hamstring Tendon

●Medial Tibia Plateu

6. Measure:
Circumference:
Amputee side Sound side
Patella Tendon Biggest calf area
Length interval 1-4 Smallest calf area
4cm above the distal end
Diameter :
- ML and AP of patella
- Suspension. Ask patient when measure the suspension, make sure patient’s enough with
the compression of the caliper
Length
- Sound side foot length
Height:
Amputee side Sound side
MTP level to distal end with soft tissue MTP to the end of the foot
MTP level to distal end without soft tissue Biggest and smallest calf to the end of the
foot

6. set the stump in correct alignment (5 degree flexion)

7. two stage casting:
 - make 3 layers slab for umbrella. Start doing casting by shaping the umbrella with slab,
make sure it shaped well
-Rolls PoP bandage from proximal to distal area
8. massage the Bandage to capture the shape of the stump
9. make sure again the alignment is correct
10. after the bandage start to set ask the patient to stand up
11. drop the plumb line in anterior and lateral side of the stump to capture the alignment line
12. take off the cast carefully, take the plastic wrap off and clean the patient
13. Evaluate the cast:
-is the marking transferred well
-shape of the cast
-cast strengths
Positive Negative
Mark is transferred well Alignment line in anterior is not in the middle
of the cast
Cast is strong enough Condyle area is not captured well
The cast is in correct angulation
Umbrella shaped well
Rectification
1. Prepare all the tools needed

-Laser level/Plumb line -Ruler

-Half round, round, and flat surform -Measurement tape
-Goniometer - Indelible pencil
-Bowl -Spatula
-Caliper -Metal and plastic wires

2.Make sure the plaster is already set

3.Put the nails on the alignment line, flexion line
4.separate the negative cast from positive cast
5.Re-mark all the markings area
6.Re-measure all measurement and compare with the measuring chart, make reduction goal
7.Trimline
 Anterior : 1/3 of the patella
 Posterior : Follow hamstring channel
  Medial : same level with adductor tubercle
 Lateral : same level with adductor tubercle

8. Alignment
● Coronal plane : Follow the stump position 0° or neutral position
● Sagittal plane : 5° of flexion
9. reduce PTB area slightly
10. reduce all the surface circumferentially to prevent cast shape changing, except umbrella
area
11. smooth the cast surface
Positive Negative
 Cast is smooth enough  Cast measurement is to big

Fabrication
1. Prepare thermocline plastic
2. Cut dacron as big as cast diameter, this will prevent the air goes out during vacuum
3. Put the cast on vacuum
4. Spray silicone spray to plastic frame
5. Put the plastic on the oven then put in on the oven upside down
6. Wait until the plastic start to drop and make bubble like shape
7. While waiting we can coat the cast with talcum powder
8. When the plastic is ready carefully place on the cast, slowly press the frame so the plastic
will follow the shape of the cast
9. Don’t forget to turn on vacuum machine
10. Take off plastic frame
11. Wait until the plastic cool
12. When the plastic is cool and hard draw the trimline and cut it
13. Take off the cast from the socket
14. Start to grind the sharp edge and smooth it

Positive Negative
 No wrinkle  The posterior trimline is to
 Inner surface smooth low
 The plastic shaped well
 Socket fitting
1. Inform the patient fitting procedure
2. Help the patient to wear silicone liner
3. Carefully donning the socket to patient
4. Start to observe

Socket fitting
First fitting Problem:the socket is loose
Solution : -

Static Fitting
Socket fitting
Coronal view The pin lock straight to the ground (abduction and
adduction in 0 degree)

Second fitting The pin lock leaning forward (slightly flexion)

 Patient Education
1. Educate the patient to donning and doffing the device
2. educate the patient to clean the device regulary using the soap water and wet towel. It
will prevent the prostesis create irritation due to dirty socket
3. educate the patient to report any problem to the device and not to fixed the problem of
the device by their self.
4. Educate the patient to regullary clean the stump

Self Critic
 increase accuracy, especially in measuring
 improve hand skills so that the project results are better