Prosthetic Practicum Study Guide

Chapter 3: Transfemoral

TF-Bench Alignment

1. 5° of socket flexion (this increase the range of usable residual limb and decrease anterior pelvic tilt). Hip flexion contracture + 5° if a contracture is present.

• This also puts the gluteus maximus muscle at a mechanical advantage for stance phase 

2. Knee axis is usually on or slightly behind foot bolt up to a 1/2”. Generally starting with the knee slightly posterior 0-3mm.

• Optimizing patient stability is the goal, promoting knee extension and foot flat quickly after initial contact. 

3. 5-7° of external knee rotation (but should be horizontal while sitting)

• This compensates for normal hip internal rotation and reduces whips

4. 5-7° toe out in relation to the socket (DO NOT do this in addition to the knee axis external rotation) 

• This matches patient sound side rotation and promotes smooth rollover over the 1st and 2nd ray of prosthetic foot. 

5. Knee center set at correct height from floor (MTP+3/8″ or 1/2″ depending on heel Ht).
6. Plumb line from ischial seat falls to center of the heel or up to 1″ lateral (outset) to heel 

• You should almost under NO circumstance inset a patients foot past the ischial seat. The goal is to increase the patient’s base of support and likely the shorter the residual limb, the more outset is required

7. Depending on the knee, the lateral socket should be bisected along the trochanter and a plumb bob should fall either through or slightly anterior to the knee axis. 

• This ensure patient optimal stability during single limb support on the prosthetic side. 

Quick Rundown: 5° degrees socket flexion, 5° external knee rotation, foot 0-1” outset, knee axis 0-1/2” posterior, 5-7° toe out. 

Tips to TF Alignment: 

Be sure to listen closely to patient scenarios during the exam as they will provide crucial information for each requested procedure. If a patient presents with a flexion contracture you must accommodate the prosthetic alignment appropriately.

• For every degree of hip flexion contracture add 5°,or for example, a patient presents with a 10° hip flexion contracture add 5° to = 15°of socket flexion. 

Transfemoral Eval & Measure

2. Eval residual limb for:
• Ischial tuberosity- to determine classification (alpha, beta, gamma).
• Check the prominence of the adductor longus/gracilis, muscle group, and depth of scarpas triangle.
• ROM/MMT (general, not in depth) – most important measure amount of flexion and/or abduction contractures.
• Measure illiofemoral angle: Place goniometer over trochanter & measure measure the adduction angle (relative to illium).
• Tissue firmness.
• Shape of the residual limb: bulbous, conical, cylindrical. 
3. Measure length from the distal aspect of the ischial tuberosity to the end of the residuum.
4. Transfer length laterally & mark 0” line, then measuring every 2” distally.
5. Measure from 0” line to apex of trochanter (measurement is generally around 2”).
6. Take circumferential measurements every 2” down (as prev. marked), using little tension.
7. Measure skeletal M/L encapsulating the ischeal tuberosity (crucial for fitting proximal aspect of the socket).
8. M/L directly below ischium.
9. M/L just above distal femur.
10. Overall length of sound side from ischial tuberosity-floor. 
11. KC-floor, foot size, ankle circ, calf circ, rest of form measurements (remember to notice if they specify cm and /or in, with/without shoes, etc.). 

ROM/MMT

In order to properly evaluate, you will need to preform basic range of motion and manual muscle testing. This is expected to be demonstrated briefly, as you will only have a limited amount of time to properly evaluate your patient. Please be familiar with the following techniques so that you will be prepared for any scenario.

1. Check Hip Abduction ROM/MMT: 0-45 (gluteus medius, minimus, tensor fascia lata, sartorious).
2. Check Hip Adduction ROM/MMT: 0-30 (adductor longus, brevis, magnus, gracillis).
3. Check Hip Flexion: 0-120 (psoas, iliacus, rectus femoris).
4. Check Hip Extension:0-20 (gluteus maximus, semi-tendinosus, membrinosus, biceps femoris).
5. Preform a Thomas test:
1. The patient is asked to lie supine. The examiner checks for lordosis, which is a predictor of a tight, hip flexor.
2. The examiner then flexes one hip bringing the knee to the chest and asks the patient to hold the knee to help stabilize the pelvis and flatten out the lumbar region. 
3. If the leg that is being tested (the leg on the table) does not have a hip flexion contraction it will remain on the testing table. If a contracture is present the leg will raise off of the table. This is often measured if present.
4. The test can also be performed with the starting position of both knees fully flexed to the chest and slowly lowering the leg being tested to see if the leg makes it to the table. 
5. Lack of Full hip extension with knee flexion less than 45° indicates iliopsoas tightness. If full extension is reached in this position it would indicate rectus femoris tightness. If any hip external rotation is observed it may indicate ITB tightness.