Crutches and crutch walking

Definition

Crutches are orthopedic devices created to assist in weight bearing when a patient has a leg injury or weakness in the lower extremities.

Purpose

Wooden or aluminum axillary (under the arm) crutches are used to assist in weight bearing when a patient has sustained an injury to the leg, knee, ankle, or foot, such as a fracture or severe sprain. Crutches are also used following surgery on the leg, knee, ankle, or foot. Forearm crutches are used to provide stability and moderate support when a patient has generalized weakness in the lower extremities, such as for a patient with cerebral palsy .

Description

Axillary crutches can be either wooden or aluminum. Each crutch is comprised of two pieces of wood or aluminum that are connected at the top and middle by a crossbar and join to a third piece that extends to the floor. The top cross bar is slightly concave in shape and fits just 1-2 inches (2.54–5 cm) below the axilla. It is covered with a soft rubber pad and is used to brace the crutches against the body. The middle cross bar is round and covered with a rubber grip. It is adjusted to hand level for gripping the crutches with the hands. The third piece connects the two upper pieces, extends to the floor, and is covered by a rubber tip on the end that meets the floor. Crutches are used in pairs to provide balance and support. Aluminum crutches are lighter and easier to use. Wooden crutches are generally less expensive than aluminum crutches.

Forearm crutches are comprised of two pieces of aluminum tubing that are telescoped one within the other to adjust to the correct height of the client. They are fitted with attached, swivel-action arm cuffs that fit partially around the forearm, and with handgrips that are covered with a rubber grip. There is a rubber tip at the end of each crutch where it meets the floor.

Operation

Wooden or aluminum axillary crutches come in several sizes. The appropriate size crutches should be selected based on the patient's height. With the patient standing straight upright, one crutch is held against the patient's side. The nut bolt which attaches to the bottom piece is loosened and removed. The crutch is then adjusted until it is l-2 inches (2.54–5 cm) below the patient's axilla. The bolt is placed in the appropriate hole, and the nut wing is tightened securely to hold it in place. The patient then holds his hand down with the elbow slightly bent. The bolt and nut wing for the handgrip are loosened and moved to the correct position for the patient. The hand should be resting at the hip line with the elbow slightly bent. The bolt is placed in the appropriate hole, and the nut wing is tightened securely. The rubber tip, rubber axillary padding, and rubber handgrip are checked to ensure placement and security. The client sits back down, and the other crutch is adjusted at the base and the hand grip to exactly match the measured crutch.

Aluminum forearm crutches come in several sizes. The appropriate size crutches should be selected based upon the patient's height. With the patient standing, one crutch is adjusted by pushing in the locking mechanism and moving the height up until the forearm portion of the crutches can slip comfortably onto the patient's arm. The crutches are locked by moving the mechanism until the lock clicks securely. The arm cuff is adjusted if necessary. The crutch is checked for stability by pushing down on it. The vinyl padding on the arm cuff, the rubber hand- grip, and the rubber tip at the end of the crutch are examined to be sure they are in place and secure. The client then sits back down, and the other crutch is adjusted to exactly match the measured crutch.

The patient should not attempt to use the crutches until they are fitted and all of the nut wings or locking mechanisms are secure. The hands and arms bear the patient's weight, not the axilla. The patient is instructed not to lean on the axillary pads because this can pinch the axillary nerve and cause numbness of the hands and arms. The patient is instructed on crutch safety, how to walk with crutches, how to go up and down stairs with crutches, how to sit, and how to stand up using the crutches. The patient demonstrates competency with the crutches before discharge. The patient is given written instructions about crutch walking and safety to review later after discharge.

Maintenance

The screw bolts and nut wings that hold the base of the crutches and the handgrip of the crutches should be checked daily to be sure they are securely tightened. Rubber tips that become worn or tear should be replaced at once to prevent slipping. Rubber handgrips that are torn or worn should be replaced promptly to prevent blisters on the hands or slipping of the hands. Worn or torn rubber padding at the top of axillary crutches should be replaced to prevent pressure injuries. New rubber tips or handgrips can be purchased at most drug stores. Crutches

that are kept in good repair can be reused if well maintained but should be re-measured and adjusted for each client. Forearm crutches should be checked daily before use to be sure that the height adjustment pegs are secure, the swivel-action arm cuffs fit correctly, the rubber tips are intact, and the handgrips are secure.

Health care team roles

It is most often the responsibility of a licensed nurse or physical therapist to fit crutches and teach crutch walking/safety to the patient in the health care setting. Non-professionals such as orthopedic technicians or ER staff can receive special training to fit crutches and teach crutch walking/safety in some medical settings. Patients must always be instructed on the proper use and safety factors involved in crutch walking prior to discharge with crutches.

Training

Instructing a patient about the safe use of crutches should include the following information:

• Crutch walking: The crutches are placed under both arms close to the body. The hands are placed firmly upon the handgrips. Both crutches and the injured limb are moved forward about 12 inches (30 cm). With the crutches braced against the body, the strength of the hands and forearms are used to push down on the hand- grips as the good leg swings through and about 12 inches (30 cm) ahead of the crutches. The patient's weight is placed on the uninjured leg and the process is repeated. A slow steady rhythm is used when walking. The patient is instructed not to go too fast or swing his leg too far forward because this can cause a loss of balance. The body and head are kept upright. The patient is instructed not to lean forward or put his weight on the axillary pads. The patient is told to look ahead to where he is going and not to look at his feet. The patient practices walking forward, turning, and walking back until he has developed a rhythm and balance with the crutches.
• Sitting: The patient is instructed to back up against the chair until he feels the chair on the back of his legs. The patient's weight is placed on the uninjured leg, and the injured leg is advanced slightly forward. Both crutches are placed side by side on the uninjured side, beside the patient's body but not under the arm. The patient holds both handgrips together and reaches back for the arm- rest of the chair with his other hand. Using the armrest of the chair and the crutch handgrips as support, the patient slowly moves his injured leg forward and lowers himself into the chair. The crutches are placed nearby. Standing them on the axillary pads, when possible, makes it less likely that they will tip over and fall away from the patient.
• Standing: When in bed, the patient moves first to a sitting position to get his balance. The patient then inches forward to the edge of the bed or the chair. Both crutches are then placed upright and side-by-side on the uninjured side. The patient grips both handgrips firmly in his hand and rises up on his uninjured leg. The crutches are placed on either side of the body and the patient holds the handgrips. Instruct the patient to take a few minutes to get his balance. Be sure that the patient's body is upright, the crutches are positioned correctly, and his head is looking forward before beginning to walk.
• Climbing up stairs: Climbing stairs with crutches requires strength and flexibility. If the patient is unsure of his strength, he should be instructed to turn around and sit on the stairs and scoot himself up one stair at a time using his uninjured leg to propel him. The patient should be instructed to keep his crutches in one hand and bring them up with him. When climbing stairs with crutches, the patient leads with his uninjured leg and brings the injured leg and crutches up behind him. If the stairway has a handrail, the patient should place both crutches under the arm opposite the handrail and grip the handgrips together in one hand. The patient places his weight on the handrail and the handgrips, leans slightly forward, and brings his uninjured leg up one step. He then brings the crutches and the injured leg up the step and advances his hand up the handrail. Once the patient has regained his balance, the process is repeated. The patient should be instructed to take his time and rest halfway up the stairs if necessary. To climb stairs with no handrail, the patient leans slightly forward and puts his weight on the handgrips of the crutches. The patient moves the uninjured leg up the step. He then shifts his weight to the uninjured leg and brings the crutches and injured leg up the step. His foot and crutch tips are kept in the middle of the step, away from the edge to avoid slipping. The patient is instructed to take his time, rest as needed, and ask for help if necessary. Having someone walk behind the patient up the stairs can add a sense of security, and the person can assist the patient into a sitting position if he becomes fatigued.
• Going down stairs: Going down stairs with crutches requires strength and flexibility. If the patient is unsure of his strength, he should sit down and scoot down the stairs one at a time, bracing himself with his good leg. The patient should keep his crutches in one hand and bring them down with him. When going down stairs with crutches, the patient should lead with his injured leg and crutches then bring his uninjured leg down behind him. If the stairway has a handrail, the patient should place both crutches under the arm opposite the handrail and grip the handgrips together in one hand. With his weight on his uninjured leg, the patient moves the crutches and the injured leg down one step. Then the patient places his weight on the handrail and the handgrips and brings his uninjured leg down the step. The patient should take time to regain his balance and repeat the process. The patient should be instructed to take his time and rest halfway down the stairs if necessary. To go down stairs with no handrail, the patient puts his weight on his uninjured leg and moves the crutches and injured leg down one step. The patient shifts his weight onto the handgrips of the crutches and brings the uninjured leg down the step. The patient keeps his foot and the crutch tips in the middle of the step, away from the edge to avoid slipping. The patient should be instructed to take his time, rest as needed, and ask for help if necessary. Having someone walk in front of the patient as he walks down the steps can add a sense of security, and the person can assist the patient into a sitting position if he becomes fatigued.
• Daily maintenance: The nut wings or locking mechanisms should be checked daily to be sure they are tightened securely. The rubber tip at the bottom of the crutches should also be checked to be sure it is secure. The tip should be replaced if it shows signs of wearing or tearing. The rubber handgrips or vinyl arm cuffs should also be examined to be sure they are intact. They should be replaced if they show signs of wearing or tearing. The rubber axillary padding should be examined and replaced if it shows signs of wearing or tearing. New rubber tips or handgrips can be purchased at most drug stores.

• General tips: Items that may cause the patient to trip and fall, such as scatter rugs or extension cords, should be removed. Spilled liquids should be wiped up to avoid slipping. Items the patient needs with him can be carried in a fanny pack, apron with pockets, or knapsack to keep his hands free to grip the crutches. A non- skid bath mat should be used in the shower or tub. A tennis shoe or other flat, rubber-soled shoe should be worn on the patient's uninjured foot to avoid slipping. The patient should be careful when going through doorways to be sure that the door does not shut on his crutches. The patient should seek help to hold the door if necessary. The patient should avoid walking through water or on icy surfaces with crutches.

KEY TERMS

Axillary —A term used to refer to the area in or around the axilla or armpit.

Resources

OTHER

"About Crutches." MediTrade Online, 2001. <http://www.meditrade.com/about_crutches.html>.

"How to Use Crutches, Canes and Walkers." About Orthopaedics. American Academy of Orthopaedic Surgeons Online. July 2000. <http://orthoinfo.aaos.org>.

"How to Use Crutches on Stairs." Physical Therapy. About.com. 2001. <http://physicaltherapy.about.com/health/physicaltherapy/library/howto/htcrutchesonstairs.htm>.

"How to Use Crutches to Walk Safely." Physical Therapy. About.com. 2001. <http://physicaltherapy.about.com/health/physicaltherapy/library/howto/htcrutchwalking.htm>.

"Using Crutches." McKinley Health Center. University of Illinois Online. November 2000. <http://www.mckinley.uiuc.edu/health-info/dis-cond/misc/usecrutc.html>.

"Walking with Crutches." Rutgers Health Online. 2001. <http://health.rutgers.edu/factsheets/crutches.htm>.

Mary Elizabeth Martelli, R.N., B.S.