orthosis and prosthesis of upper limb a brief comprehensive seminar

1. UPPER LIMB
ORTHOSES
AND
PROSTHESIS

2. INTRODUCTI
ON
“Orthosis is defined as an externally
applied device used to modify
structural and functional
characteristics of the neuro-
musculoskeletal system”
Primary goal of restoration of function
“Orthos” – to correct or maintain
straight

3. FUNCTION
S OF
ORTHOSIS
1. To immobilize or support
2. To apply traction
3. To assist weak segments
4. To substitute for absent motor
function
5. To permit controlled directional
movement
6. To allow attachment of assistive
devices
7. To block a segment

4. orthosis
static
Dynamic Static
progressive
Serial static
Classification of
orthoses

5. CONSIDERATI
ONS FOR AN
IDEAL
ORTHOSES
Sensation
Gravity
Comfort
Simplicity
Durability
Utility
Tolerance
cosmesis

6. BIOMECHANICAL
PRINCIPLES
1. 3 point mechanical pressure(Jordan’s principle)
2. Mechanical advantage
3. Torque
4. Degree and duration of stress
5. Repetitive stress
6. Control normal forces across the joint
7. Control axial forces across the joint

7. KINESIOLOGI
C
CONSIDERATI
ONS
• Role of shoulder : orientation in space
• Role of elbow: calliper to regulate distance
between hand and the body
• Role of forearm and wrist: to govern the
orientation of the hand
• Hand innumerable function
• Hand and wrist acts as a single functional
unit

8. Mainly three types of precision
pinches
1. Palmar pad pinch
2. Palmar tip pinch
3. Lateral pinch
Ideally an orthoses should be
splinted towards pad pinch
Intrinsic Minus Hand : MCP joint
hyperextension with PIP joint
and DIP joint flexion

9. STATIC
ORTHOS
ES
Therapeutic
1. Static wrist-hand orthosis(WHO)
2. Static hand orthosis(HdO)
3. Elbow orthosis(EO)
4. Shoulder-elbow orthosis(SEO)
5. Shoulder-elbow-wrist
orthosis(SEWO)

10. STATIC
WHO
Supports wrist joint
Maintains functional architecture of
the hand
Prevents deformities
Platform for therapeutic attachments

11. Patient population:
Severe weakness or paralysis of wrist and hand
Claw hand
Positional orthosis for C1-C5 quadriplegics
Attachments: MCP extension stop and IP flexion
assists
Swiwel thumb: thumb opposition

12. STATIC
HAND
ORTHOSIS(H
DO)
Hand in functional position
Prevents deformity
Therapeutic attachments
Patient population:
• Weakness hand intrinsic muscle but
strong wrist extensors
• C7 quadriplegic

13. ELBOW
ORTHOSIS-
EO
Reduce soft tissue contracture
Polypropylene bands, total
contact flexible polyethylene cuffs
and staps
Low magnitude, long duration
forces
Tease tissues into lengthening
without provoking antagonistic
response

14. Patient population:
1. Soft tissue contractures
2. Spinal cord injuries
3. Restriction after trauma
or surgery

15. SHOULDER
ELBOW
ORTHOSIS
Arm is strapped to a forearm trough
Anchored to patients pelvis
Abducted
Coupling forearm trough and iliac permits:
1. Glenohumeral internal/external rotation
2. Glenohumeral Flexion/extension
3. Elbow Flexion/extension

16. Patient population:
1. Brachial plexus injury
2. Brachial plexus injury proximal muscles
weakness
3. Painful, subluxing glenohumeral joint
Iliac cap and arm can be concealed with long
sleeve shirt
SEO + WHO/cock up : weak wrist/hand

17. SHOULDER-
ELBOW-
WRIST
ORTHOSIS
Transmits wright of the upper
limb to ipsilateral pelvis
Prevent contractures
Correct existing deformity
Relieve pain
Can be adjusted to have
mobility for rehab

18. Patient population:
1. Axillary burn: provide as much as
contact while keeping
glenohumeral in maximum
abduction
2. Rotator cuff repair
3. Anteroposterior capsular repairs
4. Post manipulations
5. Brachial plexus injuries

19. FUNCTIONAL
MODIFICATION
S
Clips and pockets that can
hold various devices
Butter fly clamps radial side
Truss stud configuration
ulnar side

20. DYNAMIC
ORTHOSES
Wrist action hand orthosis(WAWHO)
Maintains functional position of the hand
Therapeutic : protect and assist weak
extensors with mechanical wrist motion stops
Can be used with rubber band and pulley
MCP extension stop and Ip extension assists

21. Patient population:
Grade 2-3 wrist extensors and
paralysed hand muscles
If wrist extensors are grade 3+ with
good endurance, static positioning is
discontinued during the day

22. DYNAMIC
ELBOW
ORTHOSIS
Elbow: immediately after trauma or
surgery
3 point force system with hydraulic
lock
Lighter, comfortable, more hygienic,
provides optimum control at fracture
site than cast
Can be tightened or loosened
Permits limited and adjustable range
of movement

23. Patient population:
1. After cast removal for stable
fracture
2. Post operative immobilisation
3. Sprains, strains, muscle trauma
4. Dislocation
Promotes callus formation
Soft tissue healing
Avoids iatrogenic contracture

24. RATCHET
WRIST HAND
ORTHOSIS
Enables the patient to grasp and release
objects by using external power
Manually controlled
Finger flexor and extensor muscles (<grade 3)
The wrist is stabilized for function, but the
position can be changed
Thumb post is used to maintain abduction
A finger piece assembly is provided to
maintain the index and long fingers in
position for pinch

25. WRIST-
DRIVEN-
WRIST-HAND
ORTHOSIS
Transfers power from the wrist
extensors to the fingers
Active wrist extension provides grasp
Gravity-assisted wrist flexion to open
the hand
Active wrist extension results in the
fingers approximating the thumb

26. MOBILE
ARM
SUPPORT
Supports the weight of the
arm
Provides assistance to the
shoulder and elbow motions
wheelchair mounting bracket,
the proximal arm, the distal
arm, and the forearm trough

27. Patient population:
muscular dystrophy, poliomyelitis,
cervical spinal cord lesion, Guillain-
Barre´ syndrome, and amyotrophic
lateral sclerosis
Criteria for MAS use are as follows:
1. Absent or weak elbow flexion (poor
to fair)
2. Absent or weak shoulder flexion and
abduction (poor to fair)
3. Absent or weak external rotation
(poor to fair)
4. Limited endurance for sustained
upper limb activity

28. UPPER
LIMB
ORTHOS
ES FOR
STROKE
AND
BRAIN
INJURY
Treatment options for temporary
control of spasticity
1. Anaesthetic nerve blocks
2. Phenol nerve blocks
3. Chemodenervation

29. CONTRACTURE
PREVENTION
Orthoses as reinforcement after chemodenervation
1. Contracture correction
2. Maintaining limb position
3. Functional aids

30. SHOULDER
ORTHOSES:
Lap board
Arm supports
Sling
Humeral cuff
Abduction pillow
Electrical stimulation

31. ELBOW
ORTHOSES
Long arm cast
Dropout cast
Bivalved long arm cast
Dynamic elbow orthoses

32. WRIST AND
HAND
ORTHOSES
Short arm cast
Bivalved short arm cast
Volar wrist splint
Resting wrist–hand
orthoses
Dynamic wrist orthoses

33. FINGER AND
THUMB
ORTHOSES
Static hand splints
Dynamic hand splints
Split ring orthoses
Thumb spica cast
Thumb abduction splint

34. ORTHOSES IN
SPINAL CORD
INJURY
C1-c4: mouth sticks
C4-C5: BFO or mobile arm support
1. C5: over head sling
2. Electrically powered wrist extension,
flexion hinge reciprocal orthosis
3. Long opponens orthosis(ADL)
4. Dorsal wrist support
5. Ratchet WHO
6. Long wanchik

35. C6: wrist extension, finger flexion
reciprocal orthosis
1. Short opponens orthosis
2. Short wanchik
3. Universal cuff
4. Futuro wrist brace without metal
piece
C7:
1. Short wanchik
2. Short opponens orthosis
3. Universal cuff
4. Clip-on U cuff
C8: built up utensils

36. FLEXOR
TENDON
INJURIES
• Early guarded passive motion to allow
tendon glide inside the sheath
• Wrist flexion 40
• MP flexion 45
• PIP flexion 90
• DIP full flexion
• 3-4 weeks dorsal block is adjusted
• Fdsublimis and profundus: volar MP
and PIP block

37. EXTENSOR
TENDON
INJURIES
Dorsal WHO
Wrist 20 extension
Dorsal outrigger, rubber
band
controlled passive extension
and partial active flexion

38. NERVE
INJURY
Prevent deformity due to
imbalance hand
Restore full passive ROM
Achieve Full active ROM
and strength in non
affected area
Positional functioning of
hand

39. RADIAL
NERVE
INJURY
Wrist drop and drop finger
Dorsal wrist support with
dynamic extension force at
MP joint

40. ULNAR
NERVE
INJURY
Clawing of 4th and 5th fingers
Prevent hyperextension of
MP joints of 4th and 5th
digits

41. MEDIAN
NERVE
INJURY
Ape hand
Lateral pinch preserved
Goal to put thumb in
abducted and opposing
C bar/ thumb post static /
dynamic orthosis

42. DE
QUEVERAN’
S
TENOSYNOV
ITIS
Abductor pollicis longus and
extensor pollicis brevis
Wrist in neutral position
Thumb radially abducted
IP joint can be left free

43. CARPAL
TUNNEL
SYNDROME
Wrist hand orthosis
Thumb spica
Cock up wrist splint

44. FUNCTIONAL
CAST BRACING
FOR HUMERUS
FRACTURES
20 degree AP
30 degree lateral
>=3cm shortening

45. FUNCTIONAL
CAST BRACING
FOR ULNA
FRACTURE
Stabilize arm in an A/E cast
elbow in a 90 degrees of flexion
forearm in a supination
After 1st week first week brace
applied
Brace: limits pronation-
supination

46. UPPER LIMB
PROSTHESIS
“Artificial replacement for any or all parts
of the lower or upper extremities,
designed to replace as much as possible,
the function or appearance of a missing
limb or body part”

47. CHARACTERIST
ICS OF A
SUCCESSFUL
PROSTHESIS
Comfortable
Easy to wear and remove
Light weight
Durable
Cosmetically pleasing
Functioning
Minimal maintenance

48. CONSIDERATI
ONS BEFORE
PRESCRIBING
Amputation level
Contour of the Residual limb
Expected function of the Prosthesis
Cognitive function of the Patient
employment of the Patient (Desk Job vs
Manual Labour)
Avocational interests of the Patient (e.g;
Hobbies)
Cosmetic Importance of the Prosthesis
Financial resources of the Patient.

49. ETIOLOG
Y
1.Trauma
2.Tumor
3.Disease

50. AMPUTATION
LEVELS
Trans-Phalangeal Amputation
•DIP
•PIP
•MCP
•Anywhere in Between.
Trans-Metacarpal Amputation
Trans Carpel Amputation
Wrist Disarticulation
Trans-Radial Amputation
Elbow Disarticulation
Trans-Humeral Amputation
Shoulder Disarticulation
ForeQuarter

51. TYPES OF PROSTHESIS
Cosmetic functional

52. TYPES OF UPPER LIMB
PROSTHESIS
1.Body powered
2.Electrical powered prosthesis
3.Hybrid prosthesis
4.Activity specific prosthesis

53. TYPES OF FUNCTIONAL
PROSTHESIS
A. Body powered prosthesis(cable controlled)
B. Externally powered (battery/electrically prosthesis)
• Myoelectric prosthesis
• Switch controlled prosthesis

54. BODY
POWERED
PROSTHESI
S
ADVANTAGES DISADVANTAGES
Moderate Cost Most Body Movements
needed to operate
Moderately Light Weight Most Harnessing
Most Durable Least Satisfactory
appearance
Highest Sensory
Feedback
Increased Energy
Expenditure
Variety of Prehensions
available

55. EXTERNALLY
POWERED
ADVANTAGES DISADVANTAGES
Moderate or no Harnessing Heavier
Least Body movements needed to operate Most expensive
Moderate Cosmesis Most Maintaince
More Function; Proximal Areas, stronger grasp/grip in some
cases
Limited Sensory Feedback
Extended therapy time for training.

56. PARTS
All conventional body-powered prosthesis have following components:
1. SOCKET
2. SUSPENSION
3. CONTROL-CABLE SYSTEM
4. TERMINAL DEVICE
5. COMPONENTS FOR ANY INTERPOSING JOINTS AS NEEDED
ACCORDING TOTHE LEVEL OF AMPUTATION.

57. 1.SOCKE
T It has a Dual-wall design
Rigid inner socket to fit patient’s
residual limb
Outer wall designed to be of same
length and contour as that of
opposite limb.

58. 2.SUSPENSION
Harness based systems
1. Figure of 8
2. Shoulder saddle with chest strap
3. Figure of 9
4. Self suspending sockets
5. Suction sockets

59. 3.CABLE CONTROL
SYSTEM
Single control cable (Bowden)
Dual control cable (fair lead cable)
BODY MOVEMENTS CAPTURED FOR
PROSTHETIC CONTROL:
1. Gleno-Humeral Forward Flexion.
2. Gleno-Humeral Depression/Elevation,
Extension, Abduction
3. Nudge Control (for more complex
cases needing many control
functions).

60. 4.TERMIN
AL
DEVICE
Terminal device tries to replicate is
GRIP (PREHENSION).
There are 5 types of grip;
1. Precision Grip (Pincher Grip)
2. Lateral Grip (Key Pinch)
3. Tripod Grip
4. Hook-Power Grip
5. Spherical Grip

61. TYPES OF TERMINAL
DEVICES
Passive terminal devices : cosmetic > functional
 Functional : child mitt(helps in crawling)
 cosmetic
Active terminal devices: functional > cosmetic
 Body powered
 Externally powered

62. .
PROSTHETIC HAND SPLIT HOOK
Heavier in weight Lighter in Weight
More difficult to see objects being
grasped
Easier to see objects being
grasped
More complex Mechanically Simpler Mechanically
Less Versatile as a Tool Versatile as a Tool
Cannot get into pockets Will fit into Pockets
More cosmetic in appearance Not cosmetic

64. COMPONENTS FOR ANY
INTERPOSING JOINTS
1.Wrist unit
2.Elbow unit
3.Shoulder and forequarter units

65. 1.WRIS
T
UNITS
Orientation of the terminal device in
space
Held in position by friction lock/
mechanical lock
1.Quick disconnect wrist unit
 Easy swapping of terminal devices that
have special functions
2.Locking unit wrist
 To prevent rotation during grasping and
lifting
3.Wrist flexion unit
 Improves function of midline activities

67. 2.ELBO
W
UNITS
Based on the level of amputation
and the amount of residual limb
Supination/pronation decreases
after amputation
•Flexible Elbow Hinge
•Medium and Long TransRadial
Amputations
•Wrist Disarticulations
•Rigid Elbow Hinge: Short Transradial
Amputation
•Internal Locking Elbow Joint
Transhumeral Amputation.
•Internal Elbow allows 135 degree flexion

68. 3.SHOULDER
AND
FOREQUARTE
R UNITS
Functions are very difficult to restore
Weight of the unit
Diminished overall functions when
combining multiple prosthesis
Increased energy expenditure
Commonly opted are:
1. Pure cosmetic
2. No prosthesis at all

69. WHAT IS MYOELECTRIC
PROSTHESIS
Myoelectric is the electric properties of
the muscle
Myoelectric controlled prosthesis is an
externally powered artificial limb that
you control with the electrical signals
generated naturally by your own muscle

70. COMPONEN
TS
The limb consists of
a) A set of electrodes
b) A circuitry that consists of
operational amplifiers,
filters ,comparators, battery
and feedback systems
c) A relay system between the
circuitry and the robotic arm

73. RELAYING OF
INFORMATION FROM
RESIDUAL LIMB TO
ELECTRIC ARM

74. WORKING PRINCIPLES OF
OTHER TYPES OF
MYOELECTRIC ARMS:
1)Implanted myoelectric
sensors system:
These work with implants instead of electrodes, that attach to the
residual limb.
The information regarding motor impulses are transferred via a
transmitter and a telemetry controller.

75. 2)Real-time myoelectric control
of a multi-fingered hand
prosthesis using
PCA (Principle Component
Analysis)
The controller here reverts the
PCA algorithm and allows to
drive a multi- DoF hand by
combining two-differential
channels EMG input.

76. 3) RFID TAG
BASED
MYOELECTRIC
LIMBS:
WORKS
WIRELESSLY

77. APPLICATIO
NS
Movements include:
•Elbow flexion/extension
•Forearm
supination/pronation
•Opening/closing of fingers
•Quick reflexes
•Secure hold
•Grasping objects
•Comes in different sizes

78. DISADVANTA
GES
1. Motor and drive last about
two to three years.
2. When used on a child,
the sockets need to be
replaced every year
due to growth.
3. The material used in
making it may result in
skin irritations,
inflammations, infections
in the initial days.
4. Relatively expensive.

79. REFERENCES
• AAOS ATLAS OF ORTHOSIS AND ASSISTIVE DEVICES
• Upper limb orthosis by Katie D Irani
• Implications for orthotics and prosthetics in rehabilitation

80. THANK
YOU