Chapter 4

Patient Assessment

4.1. What To Assess And Now
You need to assess :
General health of the patient
The patients work and living conditions
General conditions of the stump
Joint condition
Muscle streangth
Always keep careful recorsd, because :
It helps you always collect all the data you need in a simple way.
On future visits you can remember easily any special problems they
might have.
If you need to discuss the case further with doctors or therapists, the
information can be shared with others easly.
It is sometimes useful to supplements the information on the record sheet
with photographs, special drawing, or x-rays.

4.2. General Health Of The Patient
It is very important to examine the patient carefully. The examination will
tell if the atient is ready for treatment or not. You may need to help the
stump to shrink a little more by applying a stump bandage. You will also
decide what type of prosthesis to prescribe, and any special problems to
consider.
When you assess the patiens general health, include the condition of the
sound leg. For example:
- Are they too old or frail to walk?
- Can they stand on the other leg?
4.3. The Patient Work And Living Conditional
You should also consider what kind of worl the patient does. And their
general living conditions. This will also influence the type of prosthesis
that they can use. For example:
A rice farmer will need a water-resistant leg
An office worker may want a leg that looks as real as possible
A construction worker will ned a leg that is very strong.
4.4. GENERAL CONDITION OF THE AMPTEES STUMP
There are some common problems of the stump that should be recorded in
a patient examinition:
Abrasions
These are blisters or areas of raw skin caused by rubbing between the
prosthesisi and the skin, usually over bony parts of the stump. If they occur
when a prosthesis is newly fitted, adjustment is needed.
Boils and otherskin infections
These are pus-filled infections, with a core of dead tisue, that occur usually
around a hair root. The patient should have treatment to get rid of the boil
before a prosthesis is fitted.
Bone spurs
Smetimes after an amputation, the cut and of the bone grows into a sharp
called a bone spur. These bony growths can by found by palpation, but x-
rays are needed to identify them precisely. In transtibial stumps, bone
spurs are most commonly found at the end of the fibula.
Bursa
This is a sac filled with thick fluid, whichlies under the skin as the knee.
Whwn there is a problem such as a badly-fitting prosthesis, the bursae can
swell. People usually have bursae over the patella and around the tendons
of the knee. The bursae usually protect soft tissues from the underlying
bone.
Bursae can also become infected. If his happens, the patient needs medical
treatment or a change in the prosthesis.
Discolouration
Often skin which has been damaged has an abnormal colour. Abnormal
colouring can indicate the following problems:
Pressure first reddens the skin. After several weeks, the skin
toughens and darkens to abrown colour.
Bruises cause blue, yellow, green or brown colours. These show
that blood is in the deeper layers of the skin.
Oedema reddens the skin. If it occurs for lon periods it results in
blue colours and finally in the case of chronic oedema, brown
stains are lef. These stains fade slowly and may disappear.

Skin colour is the most useful guide to show areas of pressure. It may
show the prosthesist that pressure in the socket should be changed.

Oedema
This is a collection of fluid in soft tissues of the stump. It usually
occurs after the amputation but should improve before the prosthesis is
fitted. It can be caused by a poorly fitting prosthesis.
Oedema should be reduced as much as possible before fitting is done,
otherwise the socket becomes loose too soon.
To reduce the oedema, the stump is wrapped with an elastic bandage.
How long the wrapping is needed depends on each individual case.

Plessure point
This is an area of the stump that is painful when pressure is applied.
An example is the area where the peroneal nerve passes over the lower
surface of the fibula head. Such points usually require a relief in the
socket.


Scars
There are two types of scar tissue:
Atrophic thn and easily damaged
Hypertropic thickened, painful and often stuck to the bone
Scar tissue does not stretch easily, unlike normal skin and tissue. It
must not be stretched or rubbed, or it may tear. When the scar sticks
to the bone (adherent scar), you may be able to loosen it by movement
and massage.

Trigger points
These are sensitive points on the stump tht cause pain even if only
touched lightly. Often constant pressure can be tolerated.

Stump shape
The stumps may be bulbous, cylindrical or conical. A conical stump
shrinks the least. A bulbous stump shrinks the most in the distal portions
(around the cut end of the bone)

Distal padding
The amount of tissue covering the cut end of the bone may differ very
much. When the cover is thin, it is important to be extra careful when
fitting. Stumps with heavy distal cover should be fitted with total contact
sockets to reduce the risk of oedema.
Condition of subcutaneous tissue
The stumps will shrink as the muscles waste away. Soft muscles in the
stump will waste away very quickly, wherefirm musculature will takae
longer.

Pain
Record any pain by location, degree and sensations experinced by the
patient. Sometimes pain may be left in one place but the problem causing
it is in a a different place.
It is important for the prosthetist to find out if the pain is caused by the
prosthesis or by a condition with in the stump

Patella
Sometimes the patella is damaged and painful. It can also be diseased
(for example through arthritis). This will only be a problem if it affects
the posibility of weight bearing at the tendon.
Condition of the cut end bones
Usually the fibul is shorter than the tibia, it is usually very sensitive and
care must be taken in fitting.
In some cases the fibula moves with knee flexion, but this should not be a
problemin a good fitting socket. The tips of the bones may initially be
sharp, so be careful during fitting.
After recording all the features of the stump, measuring both the stump
and the sound leg, and deciding on the type of prosthesis, take a plaster
cast of the stump. The cast will later be rectified and

4.5. JOINT CONDITION

4.6. MUSCLE STRENGTH