Sirindhorn School of Prosthetics & Orthotics
Faculty of Medicine Siriraj Hospital, Mahidol University
Transfemoral Socket Variation 1
SIPO 341 / 342
Transfemoral Prosthetics
7th June, 2011
Thanyaporn ( Poy )
Objectives
• At the end of this session, the students are
able to explain…
– The quadrilateral socket design
– The shape and function of the socket
– Clinical consideration
Contents
• Introduction to quadrilateral socket
• Function, height and shape of each wall
• Clinical considerations
Introduction to QL Socket
The quadrilateral socket is named for the
appearance of the socket when viewed in the
transverse plane. It has four sides or walls.
Anterior side
Medial side Lateral side
M-L
A-P
Posterior side
Introduction to QL Socket
Cross section at ischial tuberosity level
Adductor Rectus
longus Femoris
Gluteus
Hamstring
Maximus
Tendons
Introduction to QL Socket
• Weight bearing in the quadrilateral socket
is achieved primarily through the ischium
medially and the gluteus maximus laterlly
• The combination of skeletal and
musculature anatomy rests on the top of
the posterior wall of the socket, which is
formed into a wide seat parallel to the
ground
Introduction to QL Socket
The posterior
The ischial seat brim
Posterior view
The Medial Wall
Medial Wall
Functions :
• Provide counterforce for the lateral wall force
• Provides even pressure on the adductor muscles
for controlling the socket in adduction
– Aids in relieving for adductor longus and hamstring
tendons
• Contains all medial tissues to prevent adductor roll
• Represents the line of progression and should be
parallel to the sagittal plane
Quadrilateral socket
Anterior Posterior
Medial view
Medial Wall
• A-P dimension
– Ischial tuberosity to adductor longus tendon
** The medial wall should measure 1.5 cm less than the
actual AP distance
• Height
– The same level as ischial seat
– Can be lowered 0.5 cm to allow space for where the
pubic ramus crosses the socket wall when the pelvis
anteriorly tilts
– If an adductor roll is present it is necessary to enlarge
the wall below the brim to accommodate it
Medial Wall
For Comfort & Function
The upper 1/3 of the medial wall
is flat and vertical
The lower 2/3 of the medial wall
conforms to the stump A P
Standard socket
This wall is often lowered by
up to 0.5 cm to allow for the
pubic ramus
A P
Modified socket
The anteromedial corner
A radius for
adductor longus
and gracilis
tendons
**There should not be too large redius, a well-defined
outward flaring relief must be present
The width of the medial brim
The width of the
medial brim
**The width of the medial brim should not less than 1.5 cm
The Anterior Wall
Anterior wall
Function :
• Provides pressure across the anterior stump to
maintain placement of ischium on the seat
Quadrilateral socket
Ischial seat Anterior wall
Medial view
Anterior wall
• Counter support, intended to maintain the position
of the ischium and gluteals on the posterior seat
• The deepest point is located at 2.5 cm lateral from
the adductor longus tendon and 0.6 cm above the
ischial tuberosity level of the anterior wall of the
socket, which is carefully fitted against Scarpa’s
triangle
Anterior wall
• Height:
>> 5-6 cm higher than ischial
seat level
• The height diminishes gradually
from a point at the junction
lateral and middle third
dropping sharply as it
approaches the medial wall
• Should not limit hip flexion
Anterior wall
This wall should be as
high as possible, but
still allow the patient
to sit down and bend
over without
pressure.
The brim is flared
outward to allow for
the soft tissues of the
abdomen
Anterior wall
This part of
the socket
bulges inward
to produce a
firm and even This part
pressure over bulges
the femoral outward to
triangle. The accommodate
deepest point the rectus
of the bulge is femoris muscle
directly
opposite the
ischial seat
The Lateral Wall
Lateral wall
Function :
• Provides a surface against which the femur can
react to maintain ML pelvic stability
• Proximal to greater trochanter and it should be
contoured into and over hip abductors group
Lateral wall
• Height ranges from 5 -6 cm above the GT , should
be higher for short stump
• It flows down and into ischial seat level of the
posterior wall in smooth curve
• It should exhibit adequate adduction for each
individual patient
Lateral wall
The height of
A smooth curve lateral wall is
contributes to depend on the
supporting the stump length,
gluteus maximus the greatest
height used on
the shortest
stumps
P A
Lateral wall
Adduction angle
Their should be
enough adduction to
allow a slight stretch
of the abductors and
contouring to provide
maximum distribution
M L of pressure on the
lateral femur
Lateral wall
A gentle corner at Inside of anterior wall
the posterior shelf
allows for the
gluteus maximus
If the femur is
prominent, a
pocket should
be built in for M L
relief
The Posterior Wall
Posterior wall
Functions:
• Ischial seat provides major weight bearing surface
and the gluteus maximus laterally.
• Within the socket, the posterior wall provides a
surface for the femur to act upon to stabilize the
trunk by hip extensors
• The same action aids in voluntary knee control
Posterior wall
The ischial seat
Posterior view
Posterior wall
The posterior brim should be horizontal
The length of the prosthesis is always
measured on the ischial seat
M L
Posterior Wall
A gentle corner at
the posterior shelf
allows for the
gluteus maximus
M L
The medial-posterior corner
A radius for
hamstring
tendons
The inner surface of the posterior-medial
angulation
97-105
This provide for various gluteal musculature as well as
accommodating different size stumps
The outer edge of the posterior wall
90
This criterion leads to a normal positioning of the
prosthesis when the patient is seated
Clinical Considerations
Medial wall
• Tightness or cutting in the region of adductor
longus tendon
– Improper relief/ channel
– Medial wall is too short
(AP)
Clinical Considerations
• Crotch pressure or burning
– Medial wall is too long (AP), socket is too large
>> allow the ischium to slide off the seat into the socket >> causing ramus
pressure
– Too small socket
>> can produce a painful adductor roll
– M-L dimension of socket is too small
>> push the ischium too far medially and crowd the adductors >> check
the excessive trochanteric pressure
– Posterior brim slants downward from lateral to medial
>> cause the ischium slide medially during walking and crowd the
adductors
Clinical Considerations
• Pinching on the posteromedial corner
– Insufficient radius on the posterior and
medial wall for the hamstrings
Clinical Considerations
Anterior wall
• Pain/Pinching at the anterior medial brim
– Inadequate flaring above and medial to Scarpa’s
triangle and the pubic crest is bearing against the
socket
• “Numbness”
– Scarpa’s bulge too prominent causing localized
pressure on he femoral artery
Clinical Considerations
• Pinching in lateral 2/3 when sitting/rising
– Brim is too high and impinging on the ASIS
– Pelvic belt pinching from the brim being too low,
allowing tissue to be caught between belt and
socket
Clinical Considerations
Lateral wall
• Pain at the lateral distal of the
stump
– Inadequate relief for distal end
of the femur
– Insufficient adduction or
improper contouring of the
lateral wall to provide stabilizing
surface proximal to the end of
femur
Clinical Considerations
• Pain at proximal brim
– Insufficient relief for the greater trochanter
Clinical Considerations
Posterior wall
• “Burning” sensation at the ischial tuberosity
– First period of weight bearing with new prosthesis
– Not enough radius on the inner edge of the seat
– If occur in sitting position, may be caused by AP thickness
of the socket brim is too much >> the ischium rests on the
seat of chair >> the posterior wall pushes on hamstring
tendon
– AP of medial wall is too small, causing the ischium to be
located too far posteriorly on the seat, resulting in
excessive compression of the hamstring tendons
Clinical Considerations
• Pain at ischial tuberosity
– Socket slightly large so all weight is on the IT
– AP of medial wall is slightly large, the ischium can
be riding just on the forward edge of the seat
– Posterior wall is not horizontal in midstance >>
Slope downward from medial to lateral >>
overload on the ischium
ANY QUESTIONS??