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引言、大腿截肢病人的评估

Introduction and Assessment of Transfemoral Amputees. 引言、大腿截肢病人的评估. Dr. Winson Lee htwinson@polyu.edu.hk. 导言. Introduction. 病因 Etiology. 周边血管病变 ( PVD) 糖尿病 ( Diabetes) 创伤 ( Trauma) 感染 ( Infection) 瘤 ( Tumour) 先天性 ( Congenital).

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引言、大腿截肢病人的评估

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  1. Introduction and Assessment of Transfemoral Amputees 引言、大腿截肢病人的评估 Dr. Winson Lee htwinson@polyu.edu.hk

  2. 导言 Introduction

  3. 病因 Etiology • 周边血管病变(PVD) • 糖尿病(Diabetes) • 创伤(Trauma) • 感染(Infection) • 瘤(Tumour) • 先天性(Congenital)

  4. PVD and Diabetes mellitus accounts for 1/3 or more of all major amputation; • 周边血管病变与糖尿病占所有截肢事例之三分之一或更多 • Arteriosclerosis stops the blood flow, resulting in gangrene and amputation • 动脉硬化令血液停止流动，导致在坏疽和截肢 • About 1/3 of all people who lose a limb due to arteriosclerosis will lose the other limb within 5 years and/or die • 约三分之一因动脉硬化而失去肢体的人将在五年内丧失其他肢体/或死亡

  5. Buerger’s disease causes blood clots that stops blood flow to the lower-limb • Buerger’s disease导致血液凝块，停止血液流向下肢 • The disease is often seen in male smoker • 这种疾病常见于男性吸烟者

  6. Trauma accounts for about 25% of all amputations, especially young males; • 外伤约占所有截肢事例之25%，特别是年轻男性; • Infection, especially osteomyelitis, acuse significant number of amputations; • 感染，尤其是骨髓炎，造成大量的截肢;

  7. Tumor accounts for about 5% of all amputations, and occur primarily in teenagers; • 肿瘤约占所有截肢的5％，并主要发生在青少年; • Congenital amputations account for about 3% of all amputations, and are the major causes of children under age of 5. • 先天性截肢约占所有截肢的3％，并是5岁以下儿童截肢的主要根源。

  8. Trans-femoral prosthesis大腿假肢 Double-walled prosthetic socket 接受腔(双层) Prosthetic knee膝关节 Prosthetics foot假脚 Shank小腿连接件

  9. Quadrilateral trans-femoral socket四边形大腿假肢接受腔

  10. Quadrilateral trans-femoral socket四边形大腿假肢接受腔 • One major characteristic: • 一个主要特点: • Top of the posterior wall (horizontal in single-limb support) provides the main area of weight bearing for the ischial tuberosity • 后壁（横向单肢支持）提供坐骨结节主要承重的區域

  11. Ischial Ramus Containment socket (IRC大腿假肢接受腔)

  12. IRC socket (IRC大腿假肢接受腔) • Contain ischial tuberosity; • 包住坐骨结节; • Wider AP dimension and a narrower ML dimension; • 更广泛的前后尺寸和較窄内外尺寸;提高ML稳定性 • Allow normal femoral abduction and a narrow-base gait • 允许正常股骨内收和一个狭隘的基础步态;减小步宽 • More uniform distribution of pressure along the residual limb; • 更均匀分布残肢的压力; • Some ischial-containment sockets are made of flexible thermoplastic materials contained within a rigid frame. • 有些IRC大腿假肢接受腔由弹性的热塑性材料包著一个刚架而成

  13. Prosthetic knee joint人工膝关节 Multi axis joint 多轴人工膝关节 Single axis joint 单轴人工膝关节 Hydraulic control 液體控制的人工膝关节

  14. Instant center of knee joint瞬间膝关节中心 From full extension to full flexion, the instant center of knee joint moves posteriorly, due to the sliding of the bones 由从完全延伸至完全屈曲时，瞬间膝关节中心由于骨头滑动而向后移动 Prosthetic knee joints are designed to match the instant center of knee joint 人工膝关节是设计用来配合膝盖关的瞬间中心

  15. Types of prosthetic knees假肢的人工膝关节类型 • Prosthetic knee flexion initiated by hip flexion • 人工膝关节屈曲由髋关节屈曲发起 • Extension assist(助伸裝置) • Usually spring-loaded • 通常是弹簧加载 • The stretched spring stretched during knee flexion will assist in knee extension • 膝关节屈曲过程中，弹簧的拉伸协助膝关节伸展膝关节轴 • Knee axes • Single axis(单轴) • Polycentric axis(多中心轴) • More expensive and better, because it mimics the motion of anatomical knee joint • 更昂贵和更好，因为它模仿了膝盖关节的动作

  16. Types of prosthetic knees假肢的人工膝关节类型 • Knee friction(膝关节摩擦裝置) • Mechanical friction(机械摩擦) • Constant friction(不变的摩擦) • Friction can be adjusted(摩擦可调节) • Pneumatic(气压的) • Allow ambulation at any speed from very slow to very fast • 允许在任何速度行走，可由非常缓慢到非常快 • Less resistance at lower speeds, high resistance at higher speeds • 在较低的速度下低阻力，在更高的速度下高阻力，提高的是频率而非步长 • 快走-摩擦力大；慢走-摩擦力小，屈曲大，伸展用时长。 • Hydraulic液压的

  17. Prosthetic knee stabilization methods人工膝关节的稳定方法 • Stance-control knee(姿态控制膝盖) • Locked when weight is applied • 当施加重量時锁定 • Usually used for elderly or unstable individuals • 通常用于老年人或不稳定的人 • And those who walk on uneven surfaces • 和走在不平的表面 • Manual-lock knee(手动锁膝关节) • Locked and unlocked by manually pulling a cable • 通过手动拉电缆来锁定和解锁 • For individuals who need maximal stability because of poor coordination, poor vision, or muscular weakness • 适合对于因为协调不力，视力低下，肌肉无力而需最大稳定的人

  18. Prosthetic knee stabilization methods人工膝关节的稳定方法 • Free knee(自由膝关节) • Knee flexion can be done freely, while being stopped at full extension. • 可以自如地膝关节屈伸，但在完全伸展時停止 • Free knee is stabilized by • 自由膝盖是由以下稳定的: • ground reaction force(地面反作用力) • hip extension(髋的伸展)

  19. Suspension (悬吊) for transfemoral prosthesis Suction 真空负压 Pelvic band 腰吊带

  20. Bench alignment (工作台对线) of trans-femoral prosthesis • Sagittal(矢状面) • socket usually flexed • 接受腔通常是屈伸的——5+A° • plumb line from the greater trochanter directly through the axis of the knee (Trochanter-Knee-Ankle, TKA line) • 铅垂线从大转子直接通过膝关节轴(Trochanter-Knee-Ankle, TKA line) • Posterior position of the knee joint gives better stability • 膝关节后方的位置具有更好的稳定性，（屈曲困难） • Anterior allows better control • 而前方允许更好地控制

  21. Bench alignment (工作台对线) of trans-femoral prosthesis • Frontal plane(额状面) • aligned so that a varus moment is generated about hip joint during midstance (lateral wall placed in adduction); • 对齐使一个内翻的力矩(moment)在中立期(midstance)时在髋关节产生(即令外侧壁內收); • ischium is considered a pivot & foot is aligned directly under or up to 1 inch lateral to postero-medial wall • 坐骨被认为是一个支点而脚板則与后内侧墙的正下方或后内侧墙外移的1英寸对齐 • （坐骨结节——踝垂线） • Static alignment 静態对线 • Dynamic alignment动態对线

  22. Skeletal anatomy骨骼解剖 • Anterior view of pelvis

  23. Skeletal anatomy骨骼解剖 • 其他必要的地标 • greater trochanter(大转子) • adductor tubercle(内收肌结节) • tibial plateau(胫骨平台)

  24. Muscular anatomy肌肉解剖 • Hip extension(髋关节延长) • Gluteus maximus(臀大肌) • Hamstrings(後腿肌) • Biceps femoris long head (股二头肌长头) • Semitendinosus (半腱肌) • Semimembranosus (半膜肌)

  25. Muscular anatomy肌肉解剖 • Hip flexion(髋关节屈曲) • Psoas(腰肌) • Iliacus • Rectus femoris(股直肌) • Adductors(内收肌) • Magnus(大收肌) • Longus(内收长肌) • Brevis(内收短肌) • Sartorius(縫匠肌)

  26. Muscular anatomy肌肉解剖 • Hip adductors • Adductors(内收肌) • Longus (内收长肌) • Magnus (大收肌) • Brevis (内收短肌) • Gracilis(股薄肌)

  27. Muscular anatomy肌肉解剖 • Hip adductors • Adductors • Longus • Magnus • Brevis • Gracilis

  28. Muscular anatomy肌肉解剖 • Hip abductors(髋关节外展肌) • Gluteals(臀部肌肉) • Maximus(臀大肌) • Medius(臀中臀肌) • Minimus(臀小肌) • Tensor fasciae latea (阔筋膜张肌)

  29. Muscular anatomy肌肉解剖 • Hip rotators(髋关节旋转肌) • Semimembranosis • Semitendanosis • Gluteus minimus and medius (臀中臀肌)和(臀小肌)al • Biceps femoris longhead(股二头肌长头) • Gluteus maximus (臀大肌)al • Gemellus • Obturator internus • Quadratus femoris

  30. Regional anatomy • 边界 • Inguinal ligament(腹股沟韧带 ) • Satorus(縫匠肌) • Adductor longus (内收长肌) • Femoral triangle or “Scarpas Triangle”(股骨三角) • 血管结构: • Femoral artery and vein(股动脉和静脉) • 神经结构: • Femoral nerve(股神经)

  31. Surface anatomy表面解剖 • Muscles • Adductor longus(内收长肌) • Sartorius (縫匠肌) • Groups • Hip Flexors(髋关节屈肌) • Hip Extensors(髋关节伸肌) • Adductors(内收肌) • Abductors(外展肌) • Bony landmarks • IT(坐骨结节) • ASIS(髂前上棘) • PSIS(髂后上棘) • iliac crest(髂嵴) • Ramus(坐骨支) • Pubis(坐骨耻骨) • GT(大转子) • adductor tubercle (内收肌结节) • tibial plateau (胫骨平台) • onsFemoral triangle (股骨三角)

  32. 评估 Assessment

  33. Patient Assessment病人评估 步骤1.记下病人的细节 • Name(名称) • Age(年龄) • Sex(性别) • Height(高度) • Occupation(职业) • Date of amputation(截肢日期) • Reason of amputation(截肢原因) • …

  34. Patient Assessment病人评估 步骤2.残肢的描述 • Examine residual limb(检查残肢) • Examine the ischium(检查坐骨) • Lateral stump contour(残肢的外則轮廓) • Subcutaneous tissue(皮下組織)

  35. Examine residual limb(检查残肢) • Abrasion (擦伤), Boil (疖肿), Bone Spur (骨刺), Bursa (滑液襄), Discoloration (变色), Edema (水腫), Scar (瘢痕), Trigger points (发痛点) • Examine the ischium(检查坐骨) • Apply high pressure to the ischium, and see if the patients can tolerate; • 於坐骨施用高压力，看看病人能否耐受; • Ask if the amputee has previously worn a quadrilateral sockets. If yes, apply pressure with your fingertip at the ischium and ask if the old prosthesis press here. • 询问截肢者以前有否穿過四边形接受腔。如果是的话，适用您的指尖在坐骨上施用压力，并询问旧假肢是否按著这里的 • Lateral stump contour(残肢的外則轮廓) • Convex (凸) • Flat(平) • Concave(凹)

  36. Subcutaneous tissue(皮下組織) • Press firmly on the flesh with your finger and the thumb (muscle not involved) • 坚定地用手指和拇指按下 (不涉及肌肉) • Heavy: Over 25mm • Light: Less than 25mm • 沉重:超过25毫米 • 轻微:小于25毫米

  37. Stump musculature(残肢肌肉) • Ask the amputee to contract the muscle, while you give some resistance • 要求截肢者在你给一些阻力的情况下收缩肌肉 • Assess the hardness of the thigh muscles • 评估大腿肌肉的硬度 • Hard(硬) • Average(平均) • Soft(软)

  38. Patient Assessment病人评估 Step(步骤)3. Measure hip extension(测量髋关节延长) • Measure hip extension angle • 测量髋关节伸展角度 • Pelvis level(骨盆水平) • Place your fingers at ASIS and PSIS • 放置你的手指在髂前上棘和髂后上棘

  39. Patient Assessment病人评估 • Do extension slowly(慢地延长髋关节) • Stop and hold the position as soon as you feel the pelvis begin to rorate • 只要您觉得骨盆开始打转停止并保持這位置 • Check if there is hip flexion contracture (Thomas test) • 检查是否有髋关节屈曲挛缩(Thomas test)

  40. Patient Assessment病人评估 Step(步骤)4. Measure hip adduction(度量髋关节内收) • Record adduction angle of residuum • 记录殘肢的内收角

  41. Patient Assessment病人评估 • Step 5. Measure distance from IT to adductor longus tendon • 步骤5.测量坐骨结节与内收长肌肌腱之間的距离 • Seat the patient on a hard and flat surface • 病人坐在硬平面 • Abduct the residual limb • 殘肢外展

  42. Patient Assessment病人评估 • Instruct the amputee to adduction the residual limb while you give some resistance to this movement • 指示截肢者内收残肢，而你同時给这个运动一些阻力 • Take the measurement • 进行测量 • The distance will be used to determine the size of the brim • 距离将被用来确定口型圈的尺寸

  43. Patient Assessment病人评估 Step(步骤)6. Measure the AP dimension(测量前后尺寸) • Use the AP calipers to record the AP • 使用前后游标卡尺来记录前后尺寸 • This will be the AP from the deepest point of the Scarpa’s triangle to where the ischium sits • 这将是由股骨三角的最深點到坐骨的前后尺寸

  44. Step 7. Measure the length of the residuu • 步骤7.测量残肢的长度 • With the use of a perineal gauge • 使用一个perineal gauge • Measure femur length(测量股骨长度) • From perineum at the level of IT to the distal end of the femur • 由坐骨结节水平的会阴至股骨远端 • Measure stump length(测量残肢长度) • From perineum at the level of IT to the distal end of the residual limb • 由坐骨结节水平的会阴至残肢远端 Patient Assessment病人评估

  45. Patient Assessment病人评估 Step 8. Mark the residual limb at 5cm increments below the perineum • 步骤8.在残肢的会阴以下每5公分作标志 • Step 9. Measure and record circumferences of residual limb at the perineal level and the 5cm intervals marked on the limb • 步骤9.测量和记录残肢在会阴水平和每5公分标志的圆周

  46. Patient Assessment病人评估 • Step(步骤)10. Measure(量度): • Calf circumference at the level where is greatest and note the height; • 最大的小腿肌肉圆周;

  47. Patient Assessment病人评估 • Ankle circumference at the level where is smallest and note the height; • 最小的脚踝圆周; • Foot length, shoe heel height. • 脚长，鞋跟高度

  48. Also measure (此外量度): • IT to floor (not wearing shoes) • 从坐骨结节至地面(不穿鞋) • Tibial plateau to floor; • 从胫骨平台至地面;

  49. Top of the knee from the floor; • 从膝盖顶至地上; • ML of the contralateral knee at the femoral condyles. • 对侧的膝盖的内外尺寸(在股骨髁水平)

  50. 口型圈的选择和取模 Selecting a casting brimand casting

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