Prosthetic & Orthotic

• Introduction to Orthotics
•  Basic Terminology
•  Historical Background
•  Factors In Prescription Orthotics
•  Nomenclature of Orthotics
•  Biomechanical Principles
•  Materials Used in Orthotics Manufacturing
•  Methods of Construction
Hassan Saifullah (Prosthetist & Orthotist)
 History of Prosthetics & Orthotics
• The history of orthotic management for treatment of fractures with closed reduction and splinting dates back to Hippocrates.

• The Cairo toe Dated between 950 and 710 BC, the “Cairo toe” is the oldest prosthesis in the world. Archaeologists discovered
this artificial big toe on a female mummy near Luxor. The Cairo toe is composed of leather, molded and stained wood, and
thread.

• The devolvement of the professions of orthotic and prosthetic is closely related to three significant events in world history:
World War I, World War II, and the onset and spread of polio in the 1950s.

• The roots of prosthetics & orthotics can be traced to early blacksmiths, armor makers, other skilled artisans, and even the
individuals with amputations, who fashioned makeshift replacement limbs from materials at hand.

• Until World War II, the practice of prosthetics depended on the skills of individual craftsmen
Cairo toe 3,000-year-old 
• In 1930s a person who practice prosthetics name McKeever spent 3
years in a shop carving wood.
• Early “bracemakers” were also artisans such as blacksmiths, armor
makers, and patients who used many of the same materials as the
prosthetist: metal, leather, and wood
• These bracemakers were also frequently known as “bonesetters” until
surgery replaced manipulation and bracing in the practice of orthopedics.
“Bracemaker” then became a profession with a particular role distinct
from that of the physician
• World War II and the period following were times of significant growth
for the professions of physical therapy, prosthetics, and orthotics.
• A “ crash” Research Program was initiated by the U.S. Department of
Veterans Affairs Office of Scientific Research and Development
• As a result of this research PTB (a patella tendon bearing Prosthesis )
socket design for transtibial prosthesis and a quadrilateral socket
designed for transfemoral prosthesis.
• The needs of soldiers injured in the military conflicts in Korea and
Vietnam ensured continuing research, further refinements, and
development of new materials. The development of myoelectrically
controlled upper extremity prostheses and the advent of modular
endoskeleton lower extremity prostheses occurred in the post–Vietnam
conflict era.
• In 1940s the American Orthotic and Prosthetic Association use orthotics to
replace its professional predecessor, the Artificial Limb Manufacturers’
Association.
• Orthosis is a more inclusive term than brace.
 What is orthotics ?
• Orthotics is the branch of medical science that deal with manufacturing
and designing of braces or splints to support , relieve the weakened
segment, bone, muscle. The person who deals with the orthotics are
called orthotist

• ortho a Greek word means to straighten, to align.

• Orthotists provide care to persons with
neuromuscular and musculoskeletal
impairments that contribute to functional
limitation and disability by designing,
fabricating, and fitting orthoses
or custom-made braces.
The orthotist is responsible for evaluating
the patient’s functional and cosmetic
needs, designing the orthosis,
selecting appropriate components,
and fabricating, fitting, and aligning the orthosis.
Functions of Orthotics
• Prevent deformity
• Assist function of a weak limb
• Maintain proper alignments of joints
• Inhibit tone
• Protects against injury of weak joint
• Allow for maximal functional independence
• Facilitate motion
The orthotist educates the patient and the care providers on
appropriate use of the orthosis, care of the orthosis, and how to
assess continued appropriateness of the orthosis

What is prosthetics ?

Is the branch of medical science which deals with manufacturing and

designing of prosthesis to supersede a limb which is lost or
amputated. the person deals with prosthesis called prosthetist
Nomenclature & Terminologies of Orthotics

• Foot Orthosis (FO)

Soft FO, Rigid FO, Semi Rigid FO

• Ankle Foot Orthosis (AFO)

leaf spring AFO, Rigid AFO, Articulated AFO,

• Knee Orthosis (KO)

• Knee Ankle Foot Orthosis (KAFO)
 Thermoplastic Knee Ankle Foot Orthosis (KAFO)
 Conventional KAFO (KAFO)
 Stance Control KAFO  (KAFO)
• Hip Knee Ankle Foot Orthosis (HKAFO)
• Hand Orthosis (HO)
• Wrist Hand orthosis (HWO)
• Elbow wrist hand orthosis (EWHO)
• Shoulder elbow wrist hand orthosis (SEWHO)
• Shoulder elbow Orthosis (SEO)
• Lumbo sacral orthosis (LSO)
• Thoraco lumbo sacral orthosis (TLSO)
Hand Orthosis ?
• Positive model
• Negative model
 Material used in Orthotic Manufacturing
• Leather
• Metal
• Thermoplastic
• Thermosetting materials
• Composite material
• Foamed plastics
• Viscoelastic polymers
Leather
• leather is often preferred over synthetic substitutes because of its
superior “breathability” characteristics.
• Another important attribute of leather is its moldability.
• leather can be reinforced by lamination with plastics or other leathers
• Three basic skills are required for crafting orthotic components of leather
 Cutting, sewing and molding
• Useful qualities of leather also include its dimensional stability, porosity,
and water vapor permeability
• leather is also used for supportive components such as suspension
straps, belts, and limb cuffs
Metals
• Steel
• Aluminum
• Titanium
• magnesium
Steel
• Steels are strong, rigid, ductile, and durable, but their high density
(weight)
• Has a Susceptibility to corrosion are major disadvantages.
• Stainless steel is a steel alloy that contains 12% or more of chromium,
a material that increases resistance to corrosion
• Stainless steel used in orthotic joints.
Aluminum
• Aluminum alloys are well suited for orthotics and prosthetics because
of their high strength/weight ratio and resistance to corrosion
• Alloys are further subdivided into those that are heat treatable and
those that are not.
• Wrought aluminum alloys are used in orthotics and prosthetics for
structural purposes such as orthotic uprights, and upper extremity
devices.
• Aluminum is also susceptible for corrosion.
Titanium & Magnesium
• Titanium components are rarely used in orthotic rather than
prosthetics
• titanium alloys are stronger than those of aluminum
• Titanium alloys are also more resistant to corrosion than are
aluminum and steel.
• Magnesium alloys are lighter than those of aluminum and titanium,
are corrosion resistant
Thermoplastics
• Thermoplastic materials are formable when they are heated
but become rigid after they have cooled.
• Further classified in low temperature and high temperature
material
• Thermoplastic material acrylic, copolymer, polyethylene,
polypropylene, polystyrene, and a variety of vinyls
• low-temperature thermoplastics moldable at temperatures
less than 80°C,
Low temperature thermoplastic material
• Kydex , Orthoplast and Polysar These materials are most
often reserved for orthotic devices
• designed to provide temporary support and protection.
• susceptible to repetitive stress, high loads, and temperature
• Can be molded directly on patient no casting, special
equipment are required
Hight temperature thermoplastic material
• High-temperature plastics are frequently used in the
production of orthotics
• The most commonly used materials include polyethylene,
polypropylene, polycarbonate, acrylic, acrylonitrile butadiene
styrene (ABS), acrylics, polyvinyl acetate, polyvinyl chloride,
and polyvinyl alcohol.
• Polypropylene is a rigid plastic material that is relatively
inexpensive, lightweight, and easy to thermoform
• available in sheets of various thicknesses, from 1 mm to 1 cm.
• Polypropylene is impact resistant and can endure several
million cycles of repetitive flexes.
• This attribute has been extremely useful in orthotics for
hinge joints and spring assists in AFOs
• the material is susceptible to ultraviolet light and extreme
cold and is sensitive to scratches and nicks
• Polypropylene is commonly used for prefabricated AFOs and
preformed modular orthotic systems.
Thermosetting Materials
• Thermosets are plastics that are applied over a positive model
in liquid form and then chemically “cured” to solidify and
maintain a desired shape.
• this group of
• plastics has inherent structural stability, their rigidity precludes
modification by heat molding; their shape can only be
changed by grinding.
• Thermosetting plastics cannot be reheated without destroying
their physical properties
• Thermoset material are mostly used in lamination process of
orthotics.
• Acrylic, polyester and epoxy are the thermoset resin are used
to produce rigid orthoses.
• Acrylic resins are strong, lightweight and pliable
Composites
Composites are the combination of two or more materials with
distinctly different physical or chemical properties that together
produce a material with enhanced performance characteristics relative
to their material properties as a single substance.
• Fiber-reinforced plastics (FRPs), also referred to as composites.
• FRPs offer high strength and stiffness qualities yet are also capable of
incurring compressive or flexure stresses.
Foamed Plastics
• Foamed plastics can be used as a protective interface between
the orthotic or prosthetic and the skin,
• Classified in open and closed cell
• Closed cell are impervious to liquids, less absorb body fluids,
i.e perspiration
• Polyethylene foams are used in the manufacture of soft and
rigid orthoses, depending on the density of the material.
• Plastazote (polyethylene) is a low-temperature, heat-formable
foam that has been used successfully in the treatment and
prevention of neuropathic foot lesions.
• Its light weight and forgiving quality to bony prominences
make it a desirable interface for the insensate foot.
• Polyurethane open-cell foams are alternatives for top covers
for foot orthoses. They provide good shock absorption and
dissipate heat well.
Viscoelastic Polymers
• A viscoelastic solid is a material that possesses the
characteristics of stress relaxation and creep.
• Stress relaxation occurs when a material that is subjected to a
constant deformation requires a decreasing load with time to
maintain a steady state.
• Creep refers to the increase in deformation with time to a
steady state as a constant load applied
• Sorbothane widely used as an insole material it posses good
shock absorption characteristic
• Another type of viscoelastic solid, has attenuate skeletal shock at heel
strike in the tibia to half the normal load.
Biomechanical Principles of
orthotics
Biomechanical Principles of orthotics
• The biomechanical principles of orthotic design assist in promoting
control, correction, stabilization, or dynamic movement.

• All orthotic designs are based on three relatively simple principles

1. Pressure
2. Equilibrium
3. The lever arm principle
• These considerations include and are not limited to:

• the forces at the interface between the orthotic materials and the skin,
• the degrees-of-freedom of each joint,
• the number of joint segments,
• the neuromuscular control of a segment, including strength and tone,
• the material selected for orthotic fabrication,
• the activity level of the client.
The pressure principal
• P = force _
Area of application
1. Clinically, what this means is that the greater the area of a
pad or the plastic shell of an orthosis, the less force will be
placed on the skin. Therefore, any material that creates a
force against the skin should be of a dimension to minimize
the forces on the tissues.
The pressure principal
2. The total forces acting on the involved segment is equal to
zero or there is equal pressure throughout the orthosis and
no areas of irritation to the skin
3. The length of the orthosis is suitable to provide an
adequate force to create the desired effect and to avoid
increased transmission of shear forces against the
anatomic tissues.
The Equilibrium Principal

• The sum of the forces and the bending moments created

must be equal to zero.

• The three-point pressure or loading system occurs when

three forces are applied to a segment in such a way that a
single primary force is applied between two additional
counterforce with the sum of all three forces equaling zero
The lever Arm Principal
It states that:
The farther the point of force from the joint, the greater the
moment arm and the smaller the magnitude of force
required to produce a given torque at the joint

• The greater the length of the supporting orthotic structure,

the greater the moment or torque that can be placed on the
joint or unstable segment.
Method of construction of
Orthotics
Fabrication Process
Step 1: Taking accurate measurements of the limb
Step 2: Making a negative impression (cast)
Step 3: Creating a three-dimensional (3D) positive model of
the limb or body segment
Step 4: Modifying the positive model to incorporate the desired controls
Step 5: Fabricating the orthosis around the positive model
Step 6: Fitting of the device to the patient In some instances, further
modification or adjustment is necessary to achieve optimal fit and
function of the device.
1: Taking accurate measurements of the limb

• Bony landmarks are identified as reference points and measurements

are obtained at fixed distances from this reference.
• Measurements are recorded on forms that are specific to the body
segment
• These measurements are used in two ways
 As a efference for positive cast/model modification.
 the way to determine the placement of the trimlines of the device.
Making a negative impression (cast)
• This negative impression is most often taken with a plaster-of-Paris
bandage
• a layer of tubular stockinet or a stocking is placed over the skin to
create a protective interface
• bony prominences or other important guiding landmarks are marked
on the body segment with indelible ink.
• Vaseline is applied as hair may stuck with the –ive model, cutting aid
is applied to remove the cast easily later.
• a thin layer of plaster of Paris is wrapped around the limb.
• Rolls of elasticized plaster can be wrapped circumferentially in no
more than two or three layers.
• the clinician supports the limb or segment in the desired position
• Once the cast is hardened sufficiently, it is carefully removed from the
limb segment, preserving its shape and contours, and checked for
alignment.
• Clean the patient limb.
Creating a three-dimensional (3D) positive model
I. The negative impression is prepared by sealing the mold so that it
can accept liquid plaster of Paris.
II. Vaseline or soap is applied to the walls of A POP (plaster of Paris) is
poured in the negative model and leave it for 15- 20 (setting time of
POP ) minutes.
III. Once a model became solid negative impression is removed. +ive
model is cleaned measurements are checked.
IV. Additional plaster is added where relief of pressure is desired (e.g.,
over bony prominences) (Fig. 6.5) or is removed where additional
forces are to be applied.
• Once the desire changes is done on model. surface is prepared for
component production.
• This involves removing any surface imperfections with abrasive tools
and abrasive sanding screen e.g wire gauze, wire mesh to ensure that
the surface in contact with skin will be smooth
Fabricating the orthosis around the positive model

I. Thermoplastic sheet material is heated in an oven until it has

reached its “plastic” state.
II. The sheet is shaped over a positive model by changing the air
pressure difference across its surface (vacuum forming)
III. Once the plastic has cooled and returned to its solid state, trimlines
are delineated on the formed plastic before the edges are finished
and smoothed.
Fitting of the device to the patient
I. The orthosis is fitted to the patient with a thin layer of perlon
II. Trim lines are checked belts positioned are marked
III. Channels/relieve area are checked weather proper relive is applied
i.e. malleoli
IV. After adjusting trim line orthosis is fitted to the patient. Let him
walk if need or leave the orthosis in patient for 10-15 min.
V. After 15 min remove the orthosis check for red marks, bruises on a
patient limb
VI. Educate the patient about orthosis.
 Computer-Aided Design/
Computer-Aided Manufacture
• Currently, most CAD systems use a scanning device to record digital
information of a body segment for CAM. The primary components of
a CAD/CAM system consist of a digitizing
device, computer, and milling machine.
Surface contours of the anatomic
segment are recorded with various
digitization devices: optical-laser
scanners
Factors in Prescription of Orthotics
 Gathering data
1. Identify the impairment that require orthosis use
2. Gathering data regarding the patient’s functional
abilities or needs
3. Gathering data regarding to orthosis options and
support
4. Evaluation of data
5. Making prescription
6. Fabrication of the orthosis
Gathering data

Basic information
→ clinical record

Subjective of prescription
• Establishing subjective for orthotic use
 Prescription Procedure
The objectives of lower limb orthotic treatment
• Prevent further deformity
• Correct deformity
• Provide support for deformity
• Improve function or limitation
• Place the limb in biomechanically functional position

Maximize the patient’s quality of life

Avoid over bracing
Prescription Procedure
Physical Examination
• To identify the disorders

Places to use
inside/outside of the door, building, school,
office, hospital
Finances
• The prescription must be altered to keep
within budgets.
Evaluation of data
Type of Objectives
orthotic
Physical
Design examinations

Prescription
Pain
Components of orthosis
Material Rehabilitation or
treatment plan
Finance