Exam 4: Orthotics In- Class Quizzes

Question 1

Mrs. Smith lives next door to Mr. Jones. She was slicing tomatoes for dinner a month ago and sliced through the palm of her hand, from the webspace between her thumb and index finger to the base of the thumb. The plastic surgeon repaired muscles in the thenar eminence. Her incision is well healed, with good tissue mobility except for tightness in the web space. Her surgion is now allowing her to wear a night splint for the tightness. The best splint for her will include a ___________.

1. dorsal dynamic outrigger
2. thumb trough
3. hypthenar bar
4. C-bar

Answer 1

C-bar

Rationale: this won’t actively stretch her tissue, but it will help to have her in this static position at night. None of the other answers were better options because they didn’t address the problem.

Question 2

Another patient in the clinica is Mr. O’Brien, who cut his hand in an industrial accident and underwent repair of the extensor hood of the index finger. At 6 weeks post-op, the physician wants him placed in a splint that will assist extension and allow gentle flexion of the PIP and DIP. The best splint for this is a:

1. Dorsal index finger dynamic outrigger splint
2. Dorsal index finger static outrigger splint
3. Volar index finger dynamic outrigger splint
4. Volar index finger static outrigger splint

Answer 2

Dorsal index finger dynamic outrigger splint

Rationale: A dorsal index finger dynamic outrigger splint is the only choice that acheives what the physician requested. The volar splints assist flexion not extension. A dorsal static outrigger splint would not alow gentle flexion of the index finger.

Question 3

A few weeks after splinting, Mr. O’Brien noted pain and swelling in the PIP joint of the index finger. All of the following are possible causes of this pain except

1. Finger loop pulling at a 75* angle
2. Finger loop pulling at a 90* angle
3. shear forces at the PIP joint
4. rubber bands providing excessive tension

Answer 3

Finger loop pulling at a 90* angle

Rationale: this is the only option that is not an identified problem with fitting an outrigger. We want the loops pulling at a 90* angle to prevent shear forces at the PIP joint. Excessive tension could produce pain (because it is excessive)

Question 4

Mr. O’Brien describes his grandmother’s hand splint to you. She has rheumatoid arthritis and has been placed in a splint for night positinoning. tThis most likely is a

1. dorsal cockup wrist splint
2. long opponens WHO
3. resting pan splint
4. tenodesis splint

Answer 4

resting pan splint

Rationale: The only other good option might have been the dorsal cock-up wrist splint, but since he specified the splint was to be worn at night, the resting pan splint is a better choice. The long apponens WHO (Wrist Hand Orthosis) doesn’t do anything for RA in particular. It is like a thimb spica or thumb trough, whereas RA usually has ulnar drift (not thumb stuff). The tenodesis splint is only to assist pts using a tenodesis grip (enhances their ability to use a tenodesis grip). Dr. Bringman though we might argue with him about this question.

Question 5

A football player got his thumb hoocked in a jersey Friday night, resulting in a gamekeeper’s thumb and massive contusions to the hand. He will need immobilization of the MCP. The best split is

1. Thumb spica or post
2. thumb trough with extension stop
3. WHO with thumb in 20* flexion/adduction
4. HO with thumb in 20* flexion/adduction

Answer 5

Thumb spica or post

Rationale: None of the other options positioned the thumb well or properly immobilized splint. Thumb adduction puts the thumb too close to the palm. An extension stop allows too much movement I think.

Question 6

If he is unable to oppose the thumb to other fingers, the most likely nerve damaged is:

1. radial
2. ulnar
3. median

Answer 6

median

Rationale: the median nerve innervates the thenar muscles and lateral two lumbricals in the hand. The thenar eminence is responsible for most thumb movements. The radial nerve is only sensory in the hand. The ulnar nerve innervates the hypthenar eminence and many intrinsic hand muscles.

Question 7

A PT observes a patient during gait training. Teh patient has normal strength and equal leg length. As the patient passes midstance he slightly vaults and has early toe off. The most likely cause of this deviation is

1. excessive forefoot pronation
2. limited hamstring length
3. limited plantar flexion
4. limited dorsiflexion

Answer 7

limited dorsiflexion

Rationale: Limited dorsiflexion will restrict effective ankle rocker? I wasn’t paying close attention during class. None of the others should cause a vaulting gait or early toe off though.

Question 8

A solid ankle AFO would affect what rocker phase of gait cycle?

1. Ankle
2. Heel
3. Toe
4. All of the above

Answer 8

All of the above

Rationale: this is what dr. bringman picked as the best answer, but he said the amount it affects the toe rocker would depend on how far forward the foot plate comes. If the foot plate goes distal to the met heads, it will affect the toe rocker. If the foot rocker stops proximal to the met heads, it will essentially not affect the toe rocker.

This was a crappy question

Question 9

A patient with an AFO demonstrates genu recurvatum during the stance phase of gait. Which actions would be the most appropriate to decrease the recuvatum?

1. Increase the plantarflexion stop
2. increase the dorsiflexion stop
3. allow full range of motion at the ankle
4. ankle joint position does not affect recurvatum

Answer 9

Increase the plantarflexion stop

Rationale: increaseing the plantarflexion stop means stopping movement towards plantarflexion in a more dorsiflexed position, resulting in increased dorsiflexion. Increased dorsiflexion reduces recurvatum (but could cause knee buckling if it is too much)

Question 10

An Anterior ground reaction forrce AFO will affect which phase of gait the most?

1. Initial contact
2. Pre-swing
3. Midstance
4. Loading response

Answer 10

Midstance

Rationale: An anterior ground force reaction AFO prevent sexcessive tibial translation and is especially intened for crouch gait. Tibial translation occurs during midstance (at least that is where the most anterior translation occurs of the options given).

Question 11

John Doe is s/p CVA with right hemiparesis has difficulty ambulating secondary to toe drag and knee instability. He compromises by circumducting the lower extremity and hyperextending the knee during stance. The most appropriate orthotic choice is

1. Metal AFO with BiCAAL joint, anterior spring, posterior rod
2. Solid ankle AFO set in 5 degrees dorsiflexion
3. Solid ankle AFO set at neutral
4. KAFO with solid ankle, anterior offset knee joint

Answer 11

Solid ankle AFO set at neutral

Rationale: In this case knee instability equates to buckling. Also, Mr. Doe is pushing himself into hyperextension to compensate. The only option that might prevent hyperextension without causing knee buckling is the solid ankle AFO set at neutral. The metal AFO with BiCAAL joint, anterior spring, posterior rod would give plantar-flexion assist to neutral (where it would stop) and allow dorsiflexion. The solid ankle AFO set in 5 degrees would cause buckling (BTW 5 degrees is the max amount you would give anyone even if you wanted to give them an AFO fixed in DF). The KAFO with sold ankle and anterior offset knee joint is not correct because anterior offset is not generally used for anything. Posterior offset is used to reduce buckling because the GRF moves anterior to the KAFO joint before the natural knee would (causing an extension force). Offsetting the KAFO joint anterior to the knee is also not used to correct recurvatum either because it works better and is more functional to just lock/block the KAFO joint at neutral so the knee cannot hyperextend (since it is strapped to the neutral KAFO joint).

Question 12

Brandi is 18 years old and requires and AFO due to a compression injury to the common peroneal nerve. Her dorsiflexors are 2/5; all other muscles are 5/5. The least conspicuous AFO that is suitable for her injury is

1. solid ankle AFO
2. posterior spring leaf AFO
3. Articulating AFO with Gillete joint
4. titanium upright, biCAAL AFO

Answer 12

posterior spring leaf AFO

Rationale: One of the pros of a posterior spring leaf AFO is how low profie and inconspicuous it is. Also, it compensates for foot drop (which would be the main problem of someone with poorly functioniig dorsiflexors, but no other big problems). [another better choice would be the spiral AFO because it does the same things and is even more inconspicuous, but it was not listed as an option]. The solid ankle AFO provides more immobility and is not as low profile. A Gillete joint is usually only used in pediactrics because not sturdy enough to be used by adults. Although Brandi could almost be classified as a pediactric patient, her body is the size of an adult and would have the same effect on the gillete joint. A titanium upright, biCAAL AFO would not be low profile at all.

Question 13

Herbert is wearing a plastic KAFO on the right. during gait analysis you observe lateral trunk bending towards the orthotic side as he bears weight on the right leg at midstance. The best treatment choice to correct this problem is

1. strengthen the trunk
2. switch to a HKAFO
3. strengthen the hip abductors on the right side
4. lock the knee of the KAFO

Answer 13

strengthen the hip abductors on the right side

Rationale: Herbert is demonstrating compensated trendelenburg gait where a patient leands toward the side of weak hip abductors to minimize the drop in the contralateral hip that can happen as the result of weak hip abductors during stance phase. I believe we learned from the Neumann book and ortho last year that moving the upper body more over the hip joint axis of the weak hip (instead of between the two hips) during stance phase reduces the moment arm so there is not as much torque pushing the contralateral hip down. Dr. bringman said something about just tipping the body to try to hike to contralateral hip, but it ddin’t make sense to me. Switching to a HKAFO is unneccesary if we can strenthen the weak abductors. Locking the knee of the KAFO isn’t relevant to the problem (but it would cause more problems with his gait). Strengthening the trunk doesn’t get to the actual reason he is bending his trunk, so it probably won’t solve the problem.

Question 14

When the AFO is set in plantarflexion, the knee hyperextention

1. increases
2. decreases

Answer 14

increases

Rationale: I think Dr. bringman would say the GRF stays anterior to the knee longer, causing an extension force. I find it helpful to just imangine if my knee would want to stay extened or bend if my foot was stuck in slight PF while I was trying to walk, or stuck in slight DF while trying to walk. Imagining this or acting it out, shows me what wiould happen usually.

Question 15

Mr. Jones is a computer data entry clerk and weightlifting enthusiast. He fell asleep while tracking the Olympic weightlifting results during an all-nighter on the internet last week. His right arm was draped over the bacck of the coutch for 2 hours , and he awoke with a numb hand and weak wrist. On your examination (5 days post onset), you find that his wrist and finger extensors are 2/5. He has decreased sensation to pinprick and light touch over the dorsal thumb; also decreased over the dorsum of the hand and dorsal surfaces of the first two fingers to the MCP.

This clinical presentation is consistent with an injury to the __________ nerve.

1. median
2. ulnar
3. radial

Answer 15

radial

Rationale: he has paresthesia in the radial nerve distribution. He also has a weak wrist which could be caused by damage to the radial nerve affecting some of the extrinsic wrist extensors. This is not consistant with the sensory or motor distributions of the other two nerves.

Question 16

Mr. Jones is a computer data entry clerk and weightlifting enthusiast. He fell asleep while tracking the Olympic weightlifting results during an all-nighter on the internet last week. His right arm was draped over the bacck of the coutch for 2 hours , and he awoke with a numb hand and weak wrist. On your examination (5 days post onset), you find that his wrist and finger extensors are 2/5. He has decreased sensation to pinprick and light touch over the dorsal thumb; also decreased over the dorsum of the hand and dorsal surfaces of the first two fingers to the MCP.

You would also expect to see decreased thumb opposition with this injury

1. True
2. False

Answer 16

False

Rationale: You would expect to see decrease thumb opposition with an injury to the median nerve (which innervates the thenar eminence). The radial nerve does not innervate any intrinsic hand muscles.

Question 17

Mr. Jones is a computer data entry clerk and weightlifting enthusiast. He fell asleep while tracking the Olympic weightlifting results during an all-nighter on the internet last week. His right arm was draped over the bacck of the coutch for 2 hours , and he awoke with a numb hand and weak wrist. On your examination (5 days post onset), you find that his wrist and finger extensors are 2/5. He has decreased sensation to pinprick and light touch over the dorsal thumb; also decreased over the dorsum of the hand and dorsal surfaces of the first two fingers to the MCP.

After 2 weeks, Mr. Jones has wrist and finger extensors of 3/5. His injury was most likely

1. Neurotmesis
2. axonotmesis
3. neuropraxia

Answer 17

neuropraxia

Rationale: neuropraxia is when the myelin is damaged and the axon is minimally damaged. The axon does not degenerate but recovers relatively quickly. Since Mr. Jones is already seeing improvements in his condition, his injury can most likely be classified as neuropraxia. Also, saturday night palsy is often given as an example of neuropraxia, and Mr. Jones’ description of how his injury happened resembles satuday night palsy closely. Axonotmeisis is more severe. The neural sheath remains intact, but the axon gets damaged so much that it goes into wallerian degeneration and then re-grows. This takes more time, but the neural sheath guides the regrowth so it usually finds its target again and full recovery is likely. Neurotmesis is the most serious grade of nerve injury. Both the axon and neural sheath is damaged. This also causes wallerian degeneration, but without the sheath to guide it, the axon sprouts can get lost while trying to regrow. Full recovery may never occur, although nearby nerves can sometimes take over and innervate the tissue that lost innervation when the injury was sustained. Healing from this level of injury takes the longest.

Question 18

Mr. Jones is a computer data entry clerk and weightlifting enthusiast. He fell asleep while tracking the Olympic weightlifting results during an all-nighter on the internet last week. His right arm was draped over the bacck of the coutch for 2 hours , and he awoke with a numb hand and weak wrist. On your examination (5 days post onset), you find that his wrist and finger extensors are 2/5. He has decreased sensation to pinprick and light touch over the dorsal thumb; also decreased over the dorsum of the hand and dorsal surfaces of the first two fingers to the MCP.

Mr. Jones wants to know how long it will be until his “fingers are well.” Given your knowledge of his type of injury, you tell him that he will most likely regain full strength in

• 1-3 months
• 3-6 months
• 6-18 months
• when *#% freezes over

Answer 18

1-3 months

Rationale: Up to three months is how long it typically takes for neruopraxia to heal, and it is possible for neuropraxia to fully heal (and regain full function). axnotmeis usually takes 3-6 months to heal and also has a high liklihood of full recovery. Neurotmesis takes 6-24 months (I think that’s what Dr. B said, but 6-18 sounds good too) to reach as much recovery as possible, but has a high liklihood of never fully recovering because the sprouting axon gets lost without the neural sheath to guide it.

*check me on these times for healing (except neuropraxia, I’m sure on that one)