足部截肢的假肢處理方式課件

1、Prosthetic Treatment for Partial Foot Amputation足部截肢的假肢處理方式足部截肢的假肢處理方式Christian SchlierfProsthetist/OrthotistGuangzhou, ChinaNovember 2011足部截肢的假肢處理方式Foot bone structures（足部骨骼結(jié)構(gòu)）（足部骨骼結(jié)構(gòu)）The 27 bones of the foot skeleton（足部（足部27塊骨骼）塊骨骼）Forefoot（前足）Rear foot（后足）Digiti pedis (toes)腳趾部Metatarsus (middle

2、foot)中足Tarsus (foot root)足跟足部截肢的假肢處理方式Levels of Foot Amputations（足部截肢平面）（足部截肢平面）If amputation in the area of toes is needed, no middle or basic parts of bones should remain because they tend to deviate to wrong positions. （如果必須足趾截肢的話，中部骨骼或骨骼的根部沒有必要留下，因為它們將會偏離到錯誤位置）The disarticulation is optimal in t

3、his case as it ensures unproblematic prosthetic treatment. （假如能確保假肢安裝沒問題的話，跖趾離斷是最佳選擇）An exception is the big toe. If only the hallux is amputated, only a stiff sole and an appropriate roll-over edge would be an adequate prosthetic treatment. The shoe should have a flat sole in order to avoid too muc

4、h strain on the stump. Where toes II-V are amputated, an insole with some compensation of the shape would be appropriate. （大腳趾是個例外。如果大拇趾被截肢，具有滾動邊的硬鞋墊就是合理的假肢處理方式。應(yīng)該穿平底鞋，避免殘趾處應(yīng)力集中。第二至第五足趾截肢，殘缺部補好形狀的的鞋墊就可以。）Disarticulation of Toes（跖趾關(guān)節(jié)離斷）足部截肢的假肢處理方式International name: Trans-metatarsal peripheral amp.（國

5、際通用名:經(jīng)跖骨遠端截肢）Clinical sign: Amputation according to Sharp（臨床名：Sharp截肢)Here the amputation line goes through the heads of the metatarsus bones, therefore through the spongious bone areas. Amputations at the diaphysis level are very unfavorable because the bones thin down and become very pointed, thus

6、 making the prosthetic treatment very complicated. (截肢線經(jīng)過跖骨頭部，因此經(jīng)過跖骨髁部。經(jīng)跖骨干截肢不好，因為此處骨變小而且很尖，安裝假肢將很復(fù)雜。）The ends of the bones cut by amputation must be well curved on the plantar side. The scar should be positioned on the cranial side of the foot so that the skin of the foot sole can be pulled over th

7、e ends of the cut bones. （被截肢骨末端的足底面應(yīng)該圓滑修整，傷疤應(yīng)該安置在足背面，因此，足底皮膚可以被拉上來覆蓋截骨末端。）Transmetatarsal Amputation: Long Stump（經(jīng)跖骨截肢:長殘肢）Levels of Foot Amputations （足部截肢平面）（足部截肢平面）足部截肢的假肢處理方式International sign: Trans-metatarsal proximal amp. （國際通用名:經(jīng)跖骨遠端截肢）Clinical sign: Amputation according to Sharp-Jger（臨床名：Sh

8、arp-Jger 截肢）If the metatarsus cannot be preserved, amputation line will go through the basis of the metatarsus bones. Prosthetic device is indicated here, but an orthopedic-technical shoe treatment is recommended especially for elderly patients.（如果跖骨不能保留，截肢線應(yīng)經(jīng)過跖骨基底。此處可以安裝假肢，但要配符合矯形技術(shù)的鞋，尤其對老年人來說。）Tra

9、nsmetatarsal Amputation: Short Stump （經(jīng)跖骨截肢（經(jīng)跖骨截肢:短殘肢）短殘肢）Levels of Foot Amputations （足部截肢平面）（足部截肢平面）足部截肢的假肢處理方式Disarticulation of toes 跖趾關(guān)節(jié)離斷Transmetatarsal peripheral跖骨遠端Transmetatarsal proximal 跖骨近端Levels of Foot Amputations （足部截肢平面）（足部截肢平面）足部截肢的假肢處理方式Clinical name: Amputation according to Lisfra

10、nc （臨床名：Lisfranc 截肢）Disarticulation in the Lisfranc line cannot be treated without prosthetic problems because the bones of tarsus are of different length and the stump end is uneven. 經(jīng)Lisfranc（線離斷截肢不處理的，安置假肢會有問題，因為跗骨長短不一、殘端不平整。）If the lengths of the tarsus bones are adjusted through operation they

11、show good functional results (according to Baumgartner). 如果跗骨長度通過手術(shù)處理的話，會有很好的功能效果（ 據(jù)Baumgartner）For this type of amputation, shoe-technical possibilities are no longer enough, therefore there is a clear indication for prosthetic treatment. 這種類型截肢，矯形鞋技術(shù)已經(jīng)不夠，因此，需要安置假肢處理。Amputation in the Tarsus Area:

12、Long Stump（跗骨部截肢：遠端）（跗骨部截肢：遠端）Levels of Foot Amputations （足部截肢平面）（足部截肢平面）足部截肢的假肢處理方式Clinical name: Amputation according to Bona-Jger（臨床名：Bona-Jger 截肢）Line of distal bones of tarsus is removed and the os cuboideum is cut. Stump end is round. 跗骨遠端切除和骰骨切開，殘端變圓滑。With the amputation line moving more prox

13、imally, the tendency of the foot to move to plantarflexion increases. Moreover, the back part of the foot tends to move to supination position. 由于這種截肢太接近近端，足傾向于跖屈狀態(tài)，而且，足背部傾向于反掌運動。Through tendon caused forces single tarsus bones are likely to move to a more lateral/medial and plantar positions.由于跟腱產(chǎn)生

14、的l力作用于單一的跗骨上，使這一跗骨可能移位在更外/內(nèi)側(cè)和跖屈位上Amputation in the tarsus area - short stump （跗骨部截肢：近端）（跗骨部截肢：近端）Levels of Foot Amputations （足部截肢平面）（足部截肢平面）足部截肢的假肢處理方式Clinical sign: Disarticulation according to Chopart（臨床名：Chopart離斷）Here the amputation goes through Chopart line. To improve the loading abilities of

15、the stump, lower front edge of calcaneus should be rounded. With this amputation loading may be painful because the joints can move freely. To prevent that some surgeons shift the tendon of the m. tibialis anterior especially in younger patients. 經(jīng)Chopart線截肢，為了提高殘端的負重能力，跟骨下前沿應(yīng)該修整圓滑。這種截肢承重會造成疼痛，因為關(guān)節(jié)可

16、以自由活動。為防止這種情況，可通過手術(shù)移位脛前肌，尤其對年輕的患者。With total loss of movements in the joints of the stump in corrected plantar-flexed and supinated position, arthrodesis is possible.由于殘端關(guān)節(jié)總體運動功能喪失并處于不正確的跖屈和反掌位，故關(guān)節(jié)融合術(shù)是可能的。Amputation in the tarsus area（跗骨部截肢）跗骨部截肢）Levels of Foot Amputations （足部截肢平面）（足部截肢平面）足部截肢的假肢處理方

17、式Lisfranc amputation Lisfranc截肢Bona-Jger amputation Bona-Jger截肢Chopart amputation Chopart截肢Levels of Foot Amputations （足部截肢平面）（足部截肢平面）足部截肢的假肢處理方式In this type of amputation, the dorsal part of the cut calcaneus is overturned and put on cut end of tibia. 這種類型截肢，是把切開的跟骨背部倒轉(zhuǎn)地安置在被切除的脛骨末端。One part of the

18、skin is exposed to high pressure during loading and therefore to damage in the long term. 負重時，一部份皮膚被暴露于高壓區(qū)，長遠來講，易于損傷。Pirogow-amputation (calcaneo-tibial arthrodesis)皮羅果夫截肢（跟骨皮羅果夫截肢（跟骨脛骨融合術(shù)）脛骨融合術(shù)）Levels of Foot Amputations （足部截肢平面）（足部截肢平面）足部截肢的假肢處理方式The stump according to Syme is little shorter than

19、a Pirogow stump but it also shows excellent weight bearing ca p a c i t i e s b e ca u s e t h e amputation line goes through bones spongiosis. 塞姆截肢比皮羅果夫截肢稍微短些，具有良好的承重能力，因為截肢線經(jīng)過骨髁部位。Syme-amputation (supra-malleloar amputation)塞姆截肢（踝上截肢）塞姆截肢（踝上截肢）Levels of Foot Amputations （足部截肢平面）（足部截肢平面）足部截肢的假肢處理方式

20、PirogowAmputation皮羅果夫截肢皮羅果夫截肢Achillis (tendo calcaneus)跟腱Tibia脛骨Syme Amputation塞姆截肢塞姆截肢Talus距骨Os naviculare 足舟骨Calcaneus 跟骨 Levels of Foot Amputations （足部截肢平面）（足部截肢平面）足部截肢的假肢處理方式Biomechanical aspects（生物力學(xué)方面分析）（生物力學(xué)方面分析） “Touch sense“ (proprioception) of the foot sole足墊的足墊的”觸覺感受器觸覺感受器”（本體感覺）（本體感覺）A h

21、eel is marked as the eye of the foot because the brain receives information over the receptors of the ankles, muscles and nerves about where the foot is, which position it has and what the ground is made of. The sole of the foot has a touch sense that should stay preserved within after amputation. 足

22、跟被認為是足的眼睛，因為大腦通過踝、肌肉、神經(jīng)這些感受器接受信息：足的位置以及地面的形成。在截肢后，足墊應(yīng)該具有“觸覺感受器”的功能來反饋信息。足部截肢的假肢處理方式Biomechanical aspects（生物力學(xué)方面分析）（生物力學(xué)方面分析） Maleolus axis足部截肢的假肢處理方式Biomechanical aspects （生物力學(xué)方面分析）（生物力學(xué)方面分析） Position and posture of the end of the cut bone （殘骨的位置和姿勢）Mal-position of the foot-stump as a result of musc

23、le imbalance must be distinguished from the different functional mal-positions: 肌力不平衡導(dǎo)致的殘肢異常位必須和不同的功能位異常區(qū)分出來：Through the loss of the front part of the foot, the back part of the foot stands in an increased plantar flexed position (see picture) that must be compensated through appropriate containment

24、 in the prosthesis by positioning the remaining foot bones in a “relative dorsal extension. 由于前足的缺失，后足處于跖屈狀態(tài)（如圖），所以必須通過假肢的合適的包容來補償，使殘肢處于相對的背伸狀態(tài)。Only within a normal physiological position an appropriate scope of movement and force development for adequate plantar flexion is guaranteed. 保證正常的生理位置、合適的

25、運動范圍以及充分跖屈力的實施。足部截肢的假肢處理方式Biomechanical aspects （生物力學(xué)方面分析）（生物力學(xué)方面分析） Position and posture of the end of the cut bone（殘骨的位置和姿勢）In the frontal area occurs a similar picture with an apparent supination of the foot (see picture) without real participation of the calcaneus.在沒有跟骨的參與下，前足區(qū)出現(xiàn)如圖所示的內(nèi)翻足。The sho

26、rter the front part of the foot the closer the amputation line is to the highest point of the longitudinal arch, which creates the impression of an increased supination. 前足越短，截肢線越接近縱弓最高點，越容易形成內(nèi)翻足。These anatomical as well as functional aspects must be met within an appropriate containment and bearing

27、 of the residual limb.解剖結(jié)構(gòu)和功能方面必須融合在適當(dāng)?shù)陌菪院蜌埗说某兄匦陨?。足部截肢的假肢處理方式Biomechanical aspects （生物力學(xué)方面分析）（生物力學(xué)方面分析） Position of the mechanical roll-over edge力學(xué)滾動邊的位置 With a prosthetic device, not only the aesthetic appearance should be restored but also homologous movements and gait patterns should be ensured.

28、 一個假肢，不僅要恢復(fù)它的外觀而且要保證相應(yīng)的運動和步態(tài)模式。An important factor here is the position and the direction of the metatarsal roll-over edge. 跖趾滾動邊的位置和方向是個重要的因素。Here the proportions of the healthy foot should serve as criterion.下面是正常足比例分部，以此作為標(biāo)準。足部截肢的假肢處理方式Biomechanical aspects （生物力學(xué)方面分析）（生物力學(xué)方面分析） Position of the me

29、chanical roll-over edge力學(xué)滾動邊的位置 Foot midline 足中線10-15Foot longitudinal axis (line of progression)足縱軸（行徑線）Mechanical rool-over edge力學(xué)滾動邊Mechanical maleolus axis力學(xué)橫軸足部截肢的假肢處理方式Biomechanical aspects （生物力學(xué)方面分析）（生物力學(xué)方面分析） Length of stump after amputation in the tarsus area跗骨部截肢的殘長The picture below shows

30、amputations in the tarsus area with their approximate length differentiations. 下圖顯示了跗骨部截肢的大概長度偏差。Chopart肖帕特Pirogow皮羅果夫Syme塞姆According to Baumgartner足部截肢的假肢處理方式Measurement sheet測量表測量表 Effective heel height 有效跟高足部截肢的假肢處理方式足部截肢的假肢處理方式1.Remove uneven spots with a SURFORM rasp 用半圓銼修掉不平整的斑點。2.Flatten the

31、distal surface of the heel 把跟骨末端平面修平Model technique Add plaster 補石膏Reduce plaster 修石膏Work steps of measurement and modification technique （測量步驟和修型技術(shù)）（測量步驟和修型技術(shù)）足部截肢的假肢處理方式Type A:Rear-foot prosthesis (short foot root stump with ankle joint mobility) A型：足部假肢（短足殘肢，踝關(guān)節(jié)可活動）If movements in the upper ankle

32、 joint are possible and if they should be used with the prosthesis then the frame construction according to Botta is to recommend.如果踝上活動可以而且需要使用假肢的話，這是結(jié)構(gòu)是如果踝上活動可以而且需要使用假肢的話，這是結(jié)構(gòu)是Botta 比比較推薦的。較推薦的。The frontal height should cover more than 2/3 of the lower leg in order to distribute the pressure of th

33、e prosthesis on the tibia flares as extensively as possible.為了盡量的分布假肢在脛骨面的壓力，前緣高度應(yīng)該超過小腿的三分之二。The dorsal height should not reach higher than to the base of the m. gastrocnemius. 后側(cè)高度不應(yīng)超過腓腸肌起點。Design of a Rear-foot prosthesis（足部假肢設(shè)計）足部截肢的假肢處理方式Type A: For Rear-foot prosthesis (short foot root stump wi

34、th ankle joint mobility) A型：足部假肢（短足殘肢，踝關(guān)節(jié)可活動） Design of a Rear-foot prosthesis一種足部假肢的設(shè)計足部截肢的假肢處理方式Rear-foot Prosthesis - Type A, frame construction A型框架 Edge of cut切開邊緣Soft in-layer 軟墊層Soft in-layer 軟墊層 Lock strap 搭扣帶Axis of the stump 殘肢的軸線Core made of wood or PU foam內(nèi)芯由木頭或聚氨酯泡沫橡膠制成。PE foam or rubbe

35、r聚乙烯泡沫板或橡膠Pedilan sole Pedilan 墊足部截肢的假肢處理方式Type B: For Rear-foot prosthesis (amputation according to Pirogow and its modifications no ankle joint mobility) B型：足部假肢（適用踝骨限制活動的皮羅果夫截肢）For very sensitive and bulbous stumps, a rear-foot prosthesis with a dorsal flap door for easy donning of the prosthesis

36、 is recommended.因為這種殘端比較敏感性和類似球狀，比較推薦易于穿戴帶后片的足部假肢Design of a Rear-foot prosthesis足部截肢設(shè)計Dorsal flap door后片足部截肢的假肢處理方式Rear-foot Prosthesis - Type B, dorsal flap-door B型，帶后片型Tab扣環(huán)Modular foot component標(biāo)準足組件Soft in-layer 軟墊層Dorsal Flap 后片Locking pin 鎖閂 Lamination cut edge 板材邊緣足部截肢的假肢處理方式Type C: Rear-foo

37、t prosthesis (amputation according to Syme with a closed socket and soft-liner inlay no ankle joint mobility) C型：足部假肢（適用無關(guān)節(jié)活動的塞姆截肢，需要帶內(nèi)襯軟板封閉的接受腔）Within muscular atrophy and a resulting bulbous stump end it can be better to insert a soft socket that will compensate the greatest circumference differences. 由于肌肉萎縮和球狀的殘端，軟內(nèi)襯接受腔可補償最大圍度的偏差，有利于穿戴。The laminated container can be designed closed or with window openings. 外層可設(shè)計為封閉式或者開窗式Design of a Rear-foot prosthesis足部截