CASE BASE LEARNING

CASE BASE LEARNING CLINICAL ATTACHMENT II

VIA DARING DURING PANDEMIC COVID 19:
TRANSTIBIAL PROSTHETICS FOR FARMER

By : An’nisa Fitri Wulandari

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 TABLE OF CONTENT

⊳ CHAPTER I
○ Background, objective, benefit
⊳ CHAPTER II
○ Activity and Pathology
⊳ CHAPTER II
○ Prosthetic treatment process, treatment plan,
patient education, limitation, lesson learned,
self critic
⊳ REFERENCE

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 CHAPTER I

⊳ BACKGROUND
⊳ OBJECTIVE
⊳ REASON TO CHOOSE TOPIC
⊳ BENEFIT

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1 BACKGROUND
1 BACKGROUND

“Farmer need prosthesis

that will provide high
durability, safety and
also affordable.”
– (Kathryn, 2013)
 1 BENEFIT

OBJECTIVE
To learn more about the transitibial
prosthesis especially about the
range of components selections that
are suitable for the CBL case.
 Gain knowledge on
comprehensive and holistic
treatment of TT patient
 Gain more knowledge about the
component selections for
transtibial prosthesis
 Gain more knowledge about
exoskeletal prosthesis

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 1

Reason To Choose The Topic

Choosing components in prosthesis for a farmer is challenging.

This topic will be my key to learn more about the range of

components selections for the farmer. Also, to learn about the
alternative prescription for farmer according to whats best for him
(based on on objective asx and K level) neglect the financial issue
that is common in farmers.

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 CHAPTER II

⊳ ACTIVITY
⊳ PATHOLOGY

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 2 ACTIVITY

No. Activity Date Duration

1.  Given the case by the CA team June 23rd 2020 -
Make the Case Report based on the
information given by the CA team Varied for each
2.  and sarching for journals and article June 23rd - July 2020
day
related to the case.
Discussion regarding to the CBL Varied for each
3.  June 25th - July 2020
topic day
4.  Submit the CBL report and PPT July 24th 2020 -
5.  CBL presentation July 24th 2020 -
 2 PATHOLOGY

OPEN
FRACTURE
In this case, the patient has tibial and fibula bone
severe fracture. The tibial fractures are the most
common long bone fractures and it happened in
4% of the senior population.
 2 PATHOLOGY

OPEN The open fracture is the type of fracture which bone

FRACTURE breaks through the skin. Open fractures usually are
high-energy injuries.

The majority of the literature addressing lower-extremity trauma and

amputation has dealt with open tibial fractures. suggested absolute
indications for lower-extremity amputation is a open crushed extremity
with arterial injury and a warm ischemia time of greater than six hours.
Other relative indications for amputation include severe bone or soft-
tissue loss; an anatomic transection of the tibial nerve (Tintle, 2010).
 2 PATHOLOGY

Gustilo
Definition Example fracture patterns
type
I Open fracture, clean wound, wound <1 cm in length Simple transverse or short
oblique fractures
II Open fracture, wound > 1 cm in length without extensive soft-tissue Simple transverse or short
damage, flaps, avulsions oblique fractures
III Open fracture with extensive soft-tissue laceration, damage, or loss or High energy fracture pattern with
an open segmental fracture. This type also inculdes open fractures significant involvement of
caused by farm injuries, fractures requiring vascular repair, or fractures surrounding tissues
that have been open for 8 h prior to treatment
IIIA Type III fracture with adequate periosteal coverage of the fracture bone Gunshot injuries or segmental
despite the extensive soft-tissue laceration or damage fractures
IIIB Type III fracture with extensive soft-tissue loss and periosteal stripping Above patterns but usually very
and bone damage. Usually associated with massive contamination. contaminated
IIIC Type III fracture associated with an arterial injury requiring repair, Above patterns but with vascular
irrespective of degree of soft-tissue injury. injury needing repair
2 PATHOLOGY

So, based on the explanation above, the patient might have open
fracture type III by Gustilo Anderson classification because the massive
soft tissue damage or loss over the fracture sites, compromised
vascularity, wound contamination, and fracture instability and all of that
can lead to immeadiate amputation.

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 CHAPTER III
- DISCUSSION-
⊳ Assessment and prescription
⊳ Prosthetic making process
⊳ Fitting, patient education
⊳ Treatment plan
⊳ Limitation and summary
⊳ Lesson learned and self critic

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 3 ASSESSMENT
SUBJECTIVE • 55 years old male TT patient
ASSESSMENT (left side).
• Height 165 cm
• Weight 40 kg.
• Non primary patient.
• Has hypertension.
• Live with his wife and
children (still in school).
• His house is 1.5 hours away
from the P&O clinic.
• The reason for amputation :
A severe fracture tibia and
fibula due to a huge rock fell
onto his leg (2005).
• Doctor did amputation
immediately after he arrived
at hospital.
• Wear crutch before got his
1st prosthesis (6 months after
amputation).
 3 ASSESSMENT

SUBJECTIVE Activity daily living :

ASSESSMENT • Work as paddy farmer after the amputation.
• Working environment : muddy and uneven terrain.
• The house has no stairs and flat ground only.
• Living environment : Up and down hill road since it’s a
mountainous area.
• Goes to work by walking to save a fuel cost (1 km)
• K3 level.
 3 ASSESSMENT

Socket
PATIENT’S loose
PROBLEMS

Foot is
broken
3 ASSESSMENT

OBECTIVE • Transtibial amputee (Left side)

ASSESSMENT • Medium stump with cylindrical shape
• Good sensation and proprioception
• MS on both legs, all grade 5 except left side
knee extensor and flexor (grade 4)
• Good ROM and no contracture
• No knee ligament laxity
• Has healed wound on his stump
• Good upper limb condition
 3 ASSESSMENT
1
2

PREVIOUS
DEVICE

“Unilateral
exoskeletal TT PTB
socket and cuff
suspension”

4 5
 3 ASSESSMENT

No Gait phase Left leg (Affected Leg)

GAIT 1. Stance Coronal Plane :
DEVIATION Phase  Medial thrust (Midstance) : Due to unstable prosthesis
WITH PREV  Rotation of the foot at Heel strike : Due to the medial/lateral whip
DEVICE Sagital Plane :
 Too much knee flexion (IC-LR) : It’s because of unstable prosthesis
2. Swing Sagital Plane :
Phase  Medial/Lateral whip : Due to socket is too loose
 Pistoning : It’s because of the suspension is already broke
3. All Phase  Uneven step length longer on sound side
 Uneven timing longer on sound side
 Uneven armswing
All because of patient feel afraid and unsafe because the prosthesis is
unstable.
3 ASSESSMENT

SUPPORT HIS
PATIENT’S COMFORTABLE
WORK
EXPECTATION

STRONG DURABLE

PROSTHETIC Provide prosthesis that is strong, durable and

GOAL lightweight to support his job as a farmer, good
suspension, also easy to clean from mud and dirt
 3 PRESCRIPTION

Unilateral left side exoskeletal transtibial PTB socket with cuff suspension and SACH Foot

• Socket : PTB with polypropylene (5 mm)

• Suspension : Cuff Suspension Alignment
• Interface : 6mm soft EVA  Sagital Plane : 5 degree flexion
• Shank : Exoskeletal  Coronal Plane : Following patient’s stump
 Body of shank : Hard EVA (5 mm each)  Transverse Plane : 5 degree external
 Outer shell : Polyprophylene (5 mm) rotation of foot
• Ankle block : Made from Wooden Block
• Foot : SACH Foot

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 3 PRESCRIPTION

Unilateral left side exoskeletal transtibial PTB socket with cuff suspension and SACH Foot

• Socket : PTB with polypropylene (5 mm)

• Suspension : Cuff Suspension Alignment
• Interface : 6mm soft EVA  Sagital Plane : 5 degree flexion
• Shank : Exoskeletal  Coronal Plane : Following patient’s stump
 Body of shank : Hard EVA (5 mm each)  Transverse Plane : 5 degree external
 Outer shell : Polyprophylene (5 mm) rotation of foot
• Ankle block : Made from Wooden Block
• Foot : SACH Foot

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 3 ALTERNATIVE PRESCRIPTION

Unilateral left side endoskeletal transtibial PTB socket

with cuff suspension and dynamic response foot

• Socket : PTB with acrylic resin + carbon fiber.

• Suspension : Cuff Suspension
• Interface : EVA
• Shank : Endoskeletal with modular component
• Foot : 1C64 Triton Heavy Duty (with foot shell)
• Cosmesis : Hard Cosmesis

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 3 CASTING

• Using 1 step casting technique

• Sitting position
• Do marking on the stump
• Apply hand position and also mold
the soft tissue to make triangular
shape
• The alignment of the casting :
 Sagittal 5 flexion
 Coronal follow patient alignment
 3 RECTIFICATION

• Reduce at weight bearing ares, such as medial

tibial flare, anterior tibialis tendon and posterior
soft tissue to get the triangular shape, patella
tendon, etc.
• Build up at the bony prominence and sensitive
areas 2-3 mm.
• Make posterior wall and hamstring channel.
 3 FABRICATION

Make the Take off Assembling

Drap with
Drap Liner body of and and bench
PP
shank smoothing Alignment

1. Calculate the total height of EVAs : Length of the sound leg – (total of length of the
positive cast + ankle block + height of the prosthetic foot).
2. Cut EVAs and glue them together on top of another.
3. Make a hollow at the top side of the build up of EVA and glue them to end of positive cast.
4. Attach ankle block + foot under the build up EVA.
5. Start to shape EVA using cutter and finishing using grinding machine after take off the foot
3 FABRICATION

Make the Take off Assembling

Drap with
Drap Liner body of and and bench
PP
shank smoothing Alignment

Bench Alignment:
 Sagital Plane : 5 degree flexion
 Coronal Plane : Following patient’s stump
 Transverse Plane : 5 degree external rotation of foot
 3 FITTING

A. Static Fitting Problem

No. Problem Causes Solution
1. Pinch the skin at the posterior and The posterior trimline is too Grind the posterior trimline until
patient not able to flex up to 90 high patient can reach desired flexion
degree flexion degree
2. The foot is too much externally The foot is set in too much Re-adjust the position of the foot
rotates compared to the sound isde externally rotates
3. The prosthetic side is longer 5 mm Wrong measurement of the Add insole made from hard EVA 5
than the sound side leg during 1st meeting mm on the sound side
 3 FITTING

B. Dynamic Fitting Problem

No. Problem Causes Solution
1. Sagital Plane : The socket is too much flexion Grind a bit the wooden block at
Too much flexion of the knee the inferior side posteriorly.
joint during IC-LR
2. Uneven step length (longer  The socket too much flexion  Grind a bit the wooden block
step on the prosthetic side)  Patient still trying to adapt to the at the inferior side
new prosthesis posteriorly.
 Gait training

3. Uneven timing (longer time in  The socket too much flexion  Grind a bit the wooden block
swing phase on the prosthetic  Patient still trying to adapt to the at the inferior side
side) new prosthesis posteriorly.
 Gait training
3 EDUCATION

Patient’s Education
Use proper footwear

How to take care prosthesis

How to don and doff the prosthesis correctly

How to clean the legs and socks

How to know and what to do when there’s a problem with volume fit
When to come back for adjustment and repair
3 Comparison with experience before

It’s my first time have the case for TT patient

who works as a farmer. I never learned too
deep about component choosing for a
farmer or about exoskeletal before.
 3 Treatment Plan

 Doctor
Patient has hypertension, so it’s better for him to regulary checked his blood pressure to the
doctor.
 Diet
DASH diet (Dietary Approaches to Stop Hypertension) developed by the National Institutes of
Health USA. DASH developed to help lower blood pressure without medication. The DASH diet
encourages people to :
o Reduce the sodium and eat a variety of foods rich in nutrients that help lower blood pressure.
The recommended daily sodium intake is 1,500 mg a day of sodium as an upper limit for all
adults.
o Eat lots of whole grains, fruits, vegetables and low-fat dairy products.
o Limit the amount of alcohol and caffeine
3 Lesson Learned

The lessons that I learned from this CBL are:

• Learn deeper about other type of shank construction in TT aside from Endoskeletal,
which is Exoskeletal. It’s something that I haven’t be able to explore more during the
school year.
• Learn about the range of of transtibial prosthetics prescription for farmers. They need
prosthesis which is not only strong and durable but offer a high safety because they
work in a harsh environtmental conditions. It’s important to provide the prosthesis that
is waterproof and corrosion-resistence and easy to clean from the dust and mud. Also,
cost is usually become a huge consideration for the component choosing.
 3
Limitation During
Activity
During daring system of CA program, I can't
analyze this case in a first hand and can only
analyze based on the case study that are
given and developed them. I could’ve get
more informations regarding to the objective
assessment if I can meet the patient in a
person.
Self Critic
• I need to learn more about transtibial
prosthesis and its prescription
• I need to think broader when choosing
the prosthetics prescription and
treatment for patient
• I need to be more discipline and time-
efficient when doing the assignment
and task
 REFERENCE

• 1C60 Triton , 1C63 Triton Low Profile , 1C64 Triton Heavy Duty. (n.d.). 1–264.
• Cannada, L. K. (2016). Fracture Classification History of Fracture Classification. 182–208.
• Cross, W., & Swiontkowski, M. (2008, October 1). Treatment principles in the management of open
fractures. Indian Journal of Orthopaedics, Vol. 42, pp. 377–386. https://doi.org/10.4103/0019-
5413.43373
• Data, T. (n.d.). 1C64 Triton Heavy Duty 1C64 Triton Heavy Duty.
• Family, T. (2016). Your Life . Your Adventure . 1–16.
• G, C. (2016). Factors Associated with the Use of Endoskeletal and Exoskeletal Prosthesis Among
Lower Extremity Amputees - A Tertiary Care Centre Experience. Journal of Medical Science And
Clinical Research, 04(11), 13851–13858. https://doi.org/10.18535/jmscr/v4i11.57
• Kim, P. H., & Leopold, S. S. (2012). Gustilo-Anderson classification. Clinical Orthopaedics and
Related Research, 470(11), 3270–3274. https://doi.org/10.1007/s11999-012-2376-6
• Lusardi, M. M. (2012). Orthotics and Prosthetics in Rehabilitation - Michelle M. Lusardi, PhD, PT,
Millee Jorge, Caroline C. Nielsen, PhD - Google Books. Retrieved June 29, 2020
• Mayo Cllinic. (n.d.). Osteomyelitis - Symptoms and causes - Mayo Clinic. Retrieved July 1, 2020,
from https://www.mayoclinic.org/diseases-conditions/osteomyelitis/symptoms-causes/syc-
20375913

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• Miller, M. D. (2019). Miller’s Review of Orthopaedics E-Book - Mark D. Miller, Stephen R.
Thompson - Google Books. Retrieved June 27, 2020
• Noblet, T., Lineham, B., Wiper, J., & Harwood, P. (2019). Amputation in Trauma—How to Achieve
a Good Result from Lower Extremity Amputation Irrespective of the Level. Current Trauma
Reports, 5(1), 69–78. https://doi.org/10.1007/s40719-019-0159-1
• Petrea, C., Brusnighan, D. A., & Schweitzer, J. M. (1996). Farming with a Lower Extremity. 1–15.
• Sahoo, J., Mohanty, R. N., & Das, S. K. (2010). Comparative Study of Laminated Exoskeletal
versus Modular Endoskeletal Below Knee Prostheses. Indian Journal of Physical Medicine and
Rehabilitation, 21(1), 5–7.
• Tintle, S. M., Keeling, J. J., Shawen, S. B., Forsberg, J. A., & Potter, B. K. (2010). Traumatic and
trauma-related amputations: Part I: General principles and lower-extremity amputations. Journal of
Bone and Joint Surgery - Series A, 92(17), 2852–2868. https://doi.org/10.2106/JBJS.J.00257
• Waldera, K. E., Heckathorne, C. W., Parker, M., & Fatone, S. (2013). Assessing the prosthetic
needs of farmers and ranchers with amputations. Disability and Rehabilitation: Assistive
Technology, 8(3), 204–212. https://doi.org/10.3109/17483107.2012.699994

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THANK YOU

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