FINAL Flashcards
High level amputations
name 2
Hip disarticulation / Hemipelvectomy: they need to use more pelvic and trunk movements to advance prosthetic device, obvious gait deviations. High energy expenditure.
Hip disarticulation :
Where will WB be?
(2)
- WB will be on the IT and the overlying gluteal tissue
2. Some WB anteriorly on abdominal musculature
Hemipelvectomy
Where will WB be?
(2)
soft tissue in gluteal and lower abdominal area because disarticulation on the SI joint and smyphesis pubisi
What is energy expenditure with prosthesis in gait for high level amputation?
hemipelvectomy
disarticulation
200% of normal walking energy
*also ambulation is slow
Canadian socket
what is it
pelvic jacket
socket typically used: plastic molded jacket encompassing the residual limb: molded cast of the residual limb.
If there is a hip disarticulation still have IT on the side for WB, but if not it will be on the soft tissue
Why do we need mechanical joint alignment
to increase stability: biomechanical stability by aligning the joints in a certain way
- Hip joint: is moved slightly anteriorly to put the weight line posteriorly to create an extension moment
- Knee joint: put slightly posteriorly to put the weight line anteriorly to create an extension moment at the knee
Hip: mechanical joint alignment
- Hip joint: is moved slightly anteriorly to put the weight line posteriorly to create an extension moment
Knee: mechanical joint alignment
- Knee joint: put slightly posteriorly to put the weight line anteriorly to create an extension moment at the knee
WHy is a larger foot put on a higher level amputation prosthesis
Larger foot to increase BOS: on the prosthesis the foot is larger for more base of support A/P and M/L stability
what does the extension aide on the high level amputation do
extension aides and step control length straps so when go into swing, a posterior strap limits hip flexion to reduce the hip flexion moment
in the high level amputation how do you get knee flexion
knee flexion with a posterior pelvic tilt–sit back hard in posterior tilt in the back of the socket to collpase the hip and knee
why a soft cushion heel in the high level ampuation
to help PF
why is the high level amputation slightly shorter:
to clear the prosthetic leg
does the high level prosthesis need a torque absorber?
it is above the ankle foot assmebly because lose the tibial and femoral rotationin the transverse plane for absorption o f movements in the transverse plane
What is included on a high level prostheses
10
- WB: IT and abdominal in hip disarticulation
WB on abdominal in hemipelvectomy - canadian socket
- mechanical jt alignment of hip and knee
- larger foot to increase BOS
- strong hip extension aide and step length control
- soft cushion heel to promote PF
- prosthesis slightly shorter
- torque absorber above the ankle foot assembly
- may use shoulder strap for added suspension
- posterior pelvicc tilting for knee flexion
Bilateral LE amputation:
Prevelance
severe diabetes
PAOD: one in every 4 bilateral in3-5 yrs
Bilateral LE amputation:
E expended–implication
use wc for function
Bilateral LE amputation:
pressure distribution in socket–why need it
since they dont have a good lef to shift weight onto
Bilateral LE amputation:
lightweight material–why
to help go into swing phase in gait
Bilateral LE amputation:
increase foot length–why
increase BOS
Bilateral LE amputation:
reduce overall height–why
lower COG
Bilateral LE amputation:
torque absorber?
to absorb force in the transverse plane
Bilateral LE amputation:
Increase UE dependence
with AD because otherwise energy stored in prosthesis and wont have enough pushoff in gait –rely on UE for BALANCE and for PROPULSION
Things need in Bilateral LE amputation: 7
- WC
- comfortable pressure distribution in socket
- lightweight material
- long foot length
- reduce overall height
- torque absorbers
- increased UE dependence
* *WORK ON OVERALL BALANCE AND UE STRENGTH –ie triceps, shoulder depressors, latisimus
Bllateral Transfemoral Amputation
what type of knee unit? overall height? socks? WC? ambulation goal
1) what type of knee unit: one locked knee and one free knee with weight activated brake
2) overall height: reduce 2-3 INCHES
3) socks soft socks to have comfortable WB
4) need WC
5) ambulation goal: 100-200ft
What are stubbies
short profile prosthesis used in bilateral AK (can do 4pt gait)
Bilateral Transtibial Amputation
overall height?
ambulation goal:
AD?
1) Overall height: reduce height by 1 inch
2) Ambulation Goal: 1/3 of a mile
3) AD for balance and pushoff
lightweight material, comfortable socket
UE amputations:
cause
trauma/cancer/congenital: farming, factories,
Hand function if amputate thumb
lose 50% of hand function
Transmetacarpal amputation
what is it
proximal to MCP
Digital amputation
what is it
amputate MCP
Partial hand amputation
what is it
disarticulation at the CMCs: keep all the carpal bones but remove everything distally
(metacarpals, phalanges)
Wrist disarticulation
what is it
take all carpal bones, keep styloid processes of radius and ulna
Below Elbow amputation
what is it
keep as long as possible: at least 4cm as lever arm
25% from medial epicondyle to ulnar styloid process of good hand
Elbow amputation
what is it
take radius and ulna, keep humerus
Muscles: need strong scapula stabilizers for above elbow amputee
Shoulder amputation
what is it
take humeral head from glenoid fossa
Forequarter amputation
what is it
ie cancer patient
take scapula and clavicle and everything distal
requires a lot of surgical reattachment for scapular muscles –myoplasty and myodesis
What to consider about giving UE prosthesis
8
- skin inspection
- girth
- sensation
- ROM
- MMT: need power in body powered prosthetic device
- posture : dont want muscle imbalances
- function
- length
Muscles: need strong scapula stabilizers for above elbow amputee
Phantom pain phenomenon
who/when
more common in UE than in LE amputee,
more seen acutely closer to the surgery as time goes on it gets better:
mirror therapy
Goal for post op UE amputation
6
- promote healing
- decrease pain: desensitize/massage/TENS
- maintain residual limb ROM and prevent contracture
- maintain residual limb strength : body powered prosthesis
- independent in ADL
- residual limb shaping : want oval
Important motions: what to work on
partial hand and wrist amputation:
supination and pronation to orient distal segment
Important motions: what to work on
below elbow amputation:
elbow/shoulder/scapular motions
*ROM: will go into flexion at elbow bc lost weight
(lost pronation and supination)
Important motions: what to work on
above elbow amputation:
work on shoulder and scapular ROM
Voluntary opening device for UE
what it does
opens when move it to flexion –better option
voluntary closing device for UE
what it does
closes with shoulder flexion–not as good option for funciton
4 types of UE devices for amputation
- passive
- body powered
- external powered
- myoelectic
- passive–cosmetic not functional
- body powered: proximal movements control distal parts
- external powered: switch to flip to make it move hand
- myoelectic: combo of body power and external power
Myoelectic prosthesis
how it works
combo of body power and external power – there is a prosthetic device with EMG electrodes that recruit wen muscle activated
Passive prosthesis
how it works
cosmetic, not functional
Role of orthotics (6)
- support or brace for extremities and spine
- support due to weakness or paralysis
- protect injured / unstable joint
- produce assisted motion
- accomodate for deformity
- correct deformity
how AFO helps support
prevent footdrop in swing–ie after stroke or peroneal nerve injury
KO help protect unstable joint
if tear ACL/MCL
RGO provide assisted motion
reciprocal gait assist: one leg forward and other leg back
FO accomodate deformity
pes equinus
pes equinus deformity fixed PF: cannot change it and dont want to walk on metatarsal heads so use wedge to accomodate for WB distribution
FO accomodate deformity
pes cavus
since high medial arch, use wedge to accomodate for equal WB distribution
FO
what is it
built into shoe:
ie heel lift, medial longitudinal arch etc anything not crossing the ankle joint
AFO
what is it
short leg brace
KAFO
waht is it
long leg brace: pass the knee joint
HKAFO
high profile brace used with SCI: pelvic band, hip joint in addition to long leg brace
KO/HO
KO: just for the knee
–ie chopart strap on infrapatellar tendon to reduce pain from lateral patella tracking
HO: just for the hip
–ie afte fail total hip and have revision and put it on and lock the hip joint so not flex beyond 90 or go into adduction
CO
cervical orthosis: ie soft collar
CTO
cervical thoracic orthosis
extend down to thoracic spine
ie SOMY –sternal mandibular immobilizer
TLSO
thoracolumbosacral orthosis
ie Jewitt Brace: to put into more extended position
LSO
lumbosacral orthosis for the low back or below the thoracic spine (abdominal binder)
Reason to get a traditional vs contemporary orthosis
Traditional: metal and leather:
1) fragile skin
2) fluctuating edema
Contemporary: contemporary plastic
1) Lighter
2) custom fit
3) more cosemetic
Shoe function:
4
shoes are the base of the orthotic
- stabilize
- protect
- shock absorption
- pressure distribution
Shoe anatomy:
Sole (inner vs outer)
Heel
Upper part of the shoe
Opening
Shoe reinforcements
Sole:
inner = soft
outer = hard plastic
Heel:
spring heel =
Sole: of shoe
2
inner = soft outer = hard plastic
Heel of shoe
2
Heel:
spring heel = less than 3/4 inch
oxford heel: 3/4 to 1 inch
Upper part of shoe
3
Toe Cap = over the toes in the front of the shoes
Vamp = the rest of the front of the shoe from where maleoli are
Quarter: goes around the anatomical heel
Opening of shoe to don and doff
2
Tongue/opening:
balmoral: narrow opening
blucher: wider opening
Shoe reinforcements
2
Shoe reinforcements
toe box: more reinforced to protect the toes
counter: reinforce around the heel (good for excess hindfoot pronation/supination)
Shoe size considerations: how much space between longest toe and front?
Length: want 1/2 inch between longest toes
What width of shoe do we want?
the widest at the widest of foot at MTP
Purpose of shoe/foot orthotics
5
- shock absorption : cushioned heel
- reduce friction/ shearing/ compression on pressure sensitive areas
- modify WB pattern
- accomodate for or correct deformities
- limit motion of unstable and painful joints
What can be in shoe to reduce shock absorpbtion?
cushion heel
what can be in shoe to reduce friciton / shearing /compression on pressure sensitive areas?
GEL HEEL RELIEF PAD
What can be used to modify WB pattern in shoe
metatarsal pad
what can accomodate or correct for deformities in shoe
wedge
fixed: bring it to ground
flexible: move it to the other direction
how can shoe limit motion of unstable and painful joints
sole rocker
rocker bottom shoe to get heel to toe without moving the MTP
Types of wedge in shoe:
4
- heel wedge: hindfoot
- sole wedge: whole foot
- lateral wedge: lateral side higher
- medial wedge : medial side higher
Why use a lateral wedge?
Fixed pronation/eversion deformity = valgus deformity
Flexible supination/inversion = varus deformity
Why use medial wedge?
Fixed varus deformity: supination and inversion
Flexible Valgus deformity: pronation and eversion
What are flares?
increase the surface area and flare out the heel or sole of foot
ie for ankle sprains: if strong tendency to have inversion sprain put flares on lateral side as counterforce to prevent inversion
Lateral Flare
what it does
prevent inversion sprain / varus (most sprains are inversion)
Medial Flare
what it does
prevent pronation / valgus
Thomas heel
what is it
why
project on the MEDIAL side forward 1/4 inch (and elevate a bit like a wedge)
for pes PLANUS (flat) and pronation
Reverse Thomas heel
what is it
project on LATERAL side
Lifts
what are they and why used?
built into shoes
must be sole lift and not a heel lift if more than 1/2 inch because too much PF
LLD: of more than 1/4 inch approaching 1/2 inch is significnt
When must a heel lift be made into a sole lift?
if it is more than 1/2 inch
what is sig for LLD?
LLD: of more than 1/4 inch approaching 1/2 inch is significant
What foot insert orthotics are there?
6
- heel cushion relief
- metatarsal pad
- toe crest
- medial arch support
- custom midfoot insert (UBCL)
- heel/sole lift and wedges
where would a Thomas heel be more common?
medial side to prevent inversion
who would need a reverse thomas heel?
supinators
Who needs lifts? what type?
LLD:
if less than 1/2 inch can do heel lift
if more than 1/2 inch can do a sole lift
who does a contralateral lift?
ortho: cannot clear leg in gait
neuro: stroke has issue initiating flexion on paretic side so lift the good side to decrease friction on the floor
Rockers:
what they do
allow a nice heel to toe gait WITHOUT STRESS on the CALCANEOUS or METATARSAL HEADS
Rocker sole: rockers can be built into the sole of the shoe
Toe Rocker: angle out proximal to MTP heads
Heel Rocker: weight more forward on calcaneus
Rocker Sole
purpose
complete rocker bottom
Toe Rocker
purpsose
angle out PROXIMAL to the MTP heads:
–if painful at metatarsal heads to put weight on metatarsal shalves instead
–can be used if wounds or skin breakdown near metatarsal heads or back of calcaneus
Heel Rocker
instead of force coming in on back of heel, it is more forward on the calcaneus: roll into toe off instead of all pressure at MTP jioint it is on metatarsal shalves
6 foot insert orthotics
- heel cushion relief
- metatarsal pad
- toe crest
- medial arch support
- custom midfoot insert (UBCL)
- heel/sole lift and wedges
Heel cushion relief
what is it
gel pad:
can excavate a portion of pad to relieve pressure
create a concavity to accomodate and reduce pressures
Metatarsal Pad
what is it
ring for forefoot
–pressure on shalves and not on metatarsal heads
cookie
Toe Crest
what is it
who uses it
on plantar sulcus of toes to bring down the phalanges on the inner sole of the shoe to make contact with plantar toes TAKES AWAY PRESSURE FROM THE METATARSAL HEADS
increases area because P= F/A
for hammer toe or claw toe deformity
Medial Arch Support
when to be rigid vs when to be soft?
Rigid: for flexible deformities
Soft: for rigid deformity
Custom hind and midfoot insertion UCBL
University of california biomechanics lab:
can use in severe pes planus (first choice would be a medial wedge before a UCBL)
(can use in plantar fascitis, frontal plane abnormalities, stabilize the midfoot)
–rigid walls: high posterior, medial, lateral (control hindfoot )
–medial longitudinal arch suppport
–pes planus use a shoe with a good counter to control the hindfoot
Heel/sole Lift and wedge
Lift when? Wedge when?
lift: LLD
wedge: pronation or supination issue, equinus deformity
- -medial wedge decreases pronation for flexible deformity
- -medial wedge for fixed supination deformity
–fixed equinus deformity use heel lift
how can a wedge be used in tarsal tunnel syndrome?
when posterior tibialis comes around the medial malleoli and soem entrapment: shorten the tendon with medial wedge –more inversion and supination to shorten tibialis posterior tendon
what wedge for equinus deformity fixed?
posterior wedge
SMO: Supramalleolar Orthosis
3 reasons to use it
Low proflle AFO
–stabilize foot in frontal plane an some saggittal plane
(if want for footdrop, can only use for mild footdrop otherwise need longer profile)
–can control hindfoot pronation: need to stabilize medial arch with hindfoot pronation
–use in peds for CP: lock subtalar neutral to reduce tone in full LE
(ankle stirrup brace can be considered and SMO)
SMO:
4 things it does
- medial to lateral ankle/foot control
- mild footdrop
- severe drop of medial arch with hindfoot pronation
- tone reduction
Stirrup ankle air splint
stabilize
elastic band on bottom and two shells and goes over malleoli and inflate with air
Pediatric tone inhibiting air splint
CP: use DAFO
Hypertonicity
TBI: subtalar neutral to reduce tone in LE
Arizona Brace
corset for ankle foot complex: rigid material around malleoli (its the one with the shoelace in front)
- severe pronation / pes planus
- DJD of ankle
- posterior tibial tendonitis
- chronic achilles tendonitis
- mild foot drop
- tarsal joint instability
- chronic ankle sprains
- charcot foot –mishapen foot with flat collapsed arch –used in mild case but real boot if severe
Traditional AFO
stirrup to shank ankle joint alignment locked metal uprights calf band spring assist correction straps adjustments fitting
stirrup to shank: connect to JOINT and UPRIGHT
ankle joint alignment: level of the medial malleoli (posterior on lateral side for fibula and toe out)
locked: anterior stop prevent DF, posterior stop prevent PF
metal uprights: 1 CM SPACE BETWEEN UPRIGHT AND SKIN
calf band: end BELOW fibula head : 1-1.5 inches below fibula head to clear the common fibular nerve
spring assist : DF / PF spring assist
correction straps: valgus correction strap (medial side), varus correction strap (lateral side)
adjustments fitting:
–Calf band: 1 1/2 inch below the fibular head (1.5 inch) and do –calf band snug test
–1 cm space between upright and skin
–mechanical ankle joint level of medial malleoli: and toe out should be incorporated into the brace –lateral uprights should be more posteriorly situated relative to the medial upright
what is the stirrup to shank atachment?
bottom of shoe has metal shank connected to sole of shoe
metal peice connect to shank
stirrups connect to JOINT and UPRIGHT
Ankle joint alignment in traditional AFO?
level of the medial malleoli (distally down) :
posterior on the lateral side where fibula comes down further, allows for toe out
In traditional AFO:
posterior stop
what it prevents
prevent PF
In traditional AF:
anterior stop
what it prevents
prevent DF
In traditional AFO:
rules about metal uprights
never touch skin
1 CM SPACE BETWEEN UPRIGHT AND SKIN
In traditional AFO:
Calf band
where
terminal proximal bracne is calf band
end BELOW fibula head : 1-1.5 inches BELOW FIBULA HEAD to clear the common fibular nerve
In traditional AFO:
DF spring assist:
more common
as go into HS spring is lengthened bot controlled lengthening –it wants to pull you up into DF
as you go to DF it recoils
Control FF and assist toe clearance
In traditional AFO:
PF spring assist:
resist DF as advance to midstance and tibia comes over the foot
recoils to allow for pushoff (PF)
In traditional AFO:
Klenzac ankle
both DF and PF spring assist
In traditional AFO:
Correction strap: T strap on medial or lateral side
MEDIAL SIDE: prevent pronation
vertical strap is like a collateral ligament : if it is on the medial side like the deltoid ligament it prevents eversion
LATERAL side to prevent inversion like a lateral collateral ligament of the ankle
(used for MS and Stroke which do PF and inversion)
In traditional AFO:
Valgus correction strap
what side
MEDIAL SIDE: prevent pronation
vertical strap is like a collateral ligament : if it is on the medial side like the deltoid ligament it prevents eversion
In traditional AFO:
Varus correction strap
what side
more common
LATERAL side to prevent inversion like a lateral collateral ligament of the ankle
(used for MS and Stroke which do PF and inversion)
Fitting Considerations for traditional AFO:
–Calf band: 1 1/2 inch below the fibular head (1.5 inch) and do –calf band snug test
–1 cm space between upright and skin
–mechanical ankle joint level of medial malleoli: and toe out should be incorporated into the brace –lateral uprights should be more posteriorly situated relative to the medial upright
Plastic AFO:
- articulated vs non-articulated
- shoe insert, calf shell, calf band
- posterior leaf spring
- variable trim line
Plastic AFO
articulated vs non-articulated
usually articulated
Shoe insert, calf shell, calf band
Plastic AFO
- shoe insert: plastic part in shoe-shoe insert
- calf shell: in addition to calf band for more surface area to distribute forces
- calf band: fixate and stabilize to limb
Plastic AFO
PLS
posterior leaf spring
for FLACCID FOOT DROP (ie after stroke)
Plastic AFO
variable trim line
can be recessed back behind the malleoli
more recessed back in PLS: more flexibility –for flaccid dropfoot
but comes around further in solid plastic AFO–for severe frontal and saggital plane tone and severe equino varus
Toe off brace
provide DF resistance until midstance and heelrise and provide PF energy return at toe off
(a blue rocker is a more rigid toe off brace)
Hemispiral Brace
**good brace for equino varus ** (PF and inversion)
because it is like the lateral collateral:
comes over lateral malleoli and spirals around posteriorly and wraps around medially
AFO consideration
Stairs Ramps Sit to stand posture adjsutments cycling/nustep DF ace wrap
Stairs: may do step two pattern (ie liek in ski boot)
Ramps: smaller steps because DF/PF limited
Sit to stand: hard to get foot under with limited DF
posture adjustments: may take away ankle strategy and use hip strategy
cycling/nustep: take off brace first
DF ace wrap: anchor in DF
AFO Checkout
PLASTIC
(6)
- no excess pain from trim lines and bony prominence: if red do capillary refill test (need shoe fit well)
- wearing schedule: build up tolerance
- relief of pressure sensitive areas
- ambulating: no gapping or pistoning between brace and limb
- good fit inside supportive shoe
- no skin irritation when removed
AFO Chechout
TRADITIONAL
- uprights 1cm from skin
- good alignment of mechanical and anatomical joint (allow for toe out)
- clear fibula head
- no calf band irritation
Calf band: 1 1/2 inch below the fibular head (1.5 inch) and do –calf band snug test - shoe that is attached fits properly
- closures secure and easy to operate
KO
reasons to use one
after surgery
brace in functional activity
brace for arthritis
patellofemoral issues
KO: 4 things that it can be in options
length
material
axis
motion
- short or long prodile
- soft or rigid material
- single axis or polycentric (match anatomical joint after ACL)
- restrict saggital/frontal/and transverse plane motion–prevent terminal extension to prevent rotation
Type of Postop KO
what do they have
3 types
Longer profile
dial locks–can lock in a range
expandable–velcro in case edema
- zimmer splint: no joint, velcro–good for edema (ie after quadriceps tendon tear)
- genutec: hinged brace with joint (bledso)
- ottobok knee immobilizer –cannot bend knee
Functional KO
when are they worn
why
4 type
- ADL, recreational activity
- to prevent excess motion / stabilize joint (ie post ACL repair)
GLADIATOR BRACE: medial and lateral uprights and a hinge joint for more medial and lateral stability of the knee
POST OP ACL BRACE: may allow some flexion but limit terminal extension so not get the rotation
FUSION BRACE: post ACL repair –able to move around and walk but not stress ACL
SWEDISH KNEE CAGE: prevent genu recurvatum –can sit, bend knee, prevent hyperextension (anterior force in popliteal and posterior force above and below)
gladiator brace
what is it
GLADIATOR BRACE: KO with medial and lateral uprights and a hinge joint for more medial and lateral stability of the knee
fusion brace
what is it
post op ACL repair –able to move around and walk but not stress ACL
swedish knee cage
what is it
prevent genu recurvatum –can sit, bend knee, prevent hyperextension (anterior force in popliteal and posterior force above and below)
Unloading Knee Orthosis
- braces designed for unloading at the knee joint ie valgus and varus correction braces: reduce medial/lateral compression by applying varus/valgus force
- lateral uprights on both sides for ligamentus instability for frontal plane stability without a corrective force
- OA: if pain in lateral joint: want a valgus correction brace to apply force laterally
if medial joint pain want varus correction brace
Varus Correction brace
lateral upright has a compression pad that applies pressure medially to decrease compression on medial side of joint
and reduce ligament strain on lateral side of joint
Valgus Correction brace
medial upright has a compression pad that applies pressure laterally to decrease compression on lateral side of joint
and reduce ligament strain on medial side of joint
Patellofemoral Orthosis
anterior knee pain (crepitus, pain behind knee cap) and control lateral tracking
- Chopart Strap: around infrapatella tendon to prevent kneecap tracking SUPERIOR
- Taping: control patella
- Lateral Restraining Bar: prevent knee cap ,oving too far laterally
- Palumbo: straps pull medially to prevent lateral patella tracking
Polumbo:
for excess lateral patella tracking:
straps pull medially to prevent lateral patella tracking
Chopart Strap:
around infrapatella tendon to prevent kneecap tracking SUPERIOR
KAFO
why it is used
what material
3 components
knee ankle foot orthosis
- for knee and ankle control
- traditional (leather and metal) vs plastic (thigh shell and calf shell, custom made)
3 components: AFO / knee joint with pad / thigh component
KAFO:
types of knee joints
uniaxial:
polycentric:
posterior offset knee joint: take mechanical knee joint and move it back: to increase extension moment by putting weight line in front
-can have a drop ring lock
KAFO
Drop ring lock–
normally it is up: stand and extend the knee to drop it down to lock the knee
Types of knee locks
drop ring lock: normally it is up: stand and extend the knee to drop it down to lock the knee
cam lock (with bail release = pawl lock): wire in popliteal area and pull to release knee –always locked and then release it to sit
Fan lock: lock in one degree setting ie always 20 degrees
Dial lock : allows for a range ie a desginated amount of flexion extension
Types of knee locks
for KAFO
4
drop ring lock: normally it is up: stand and extend the knee to drop it down to lock the knee
cam lock (with bail release = pawl lock): wire in popliteal area and pull to release knee –always locked and then release it to sit
Fan lock: lock in one degree setting ie always 20 degrees
Dial lock : allows for a range ie a desginated amount of flexion extension
cam lock
cam lock (with bail release = pawl lock): wire in popliteal area and pull to release knee –always locked and then release it to sit
fan lock
Fan lock: lock in one degree setting ie always 20 degrees
dial lock
Dial lock : allows for a range ie a desginated amount of flexion extension
Stance control KAFO
knee always locked in stance but when DF it pulls cable to DISENGAGE THE KNEE JOINT AND IT WILL COLLAPSE THE KNEE TO PREPARE FOR SWING
indication for stance control KAFO (4)
knee always locked in stance but when DF it pulls cable to DISENGAGE THE KNEE JOINT AND IT WILL COLLAPSE THE KNEE TO PREPARE FOR SWING
- good for quad paralysis
- quad weakness due to polio
- incomplete SCI
- femoral nerve neuropathy
role of AFO to control Knee motion
into HS: posterior shell anterior directed force : for knee flexion
into MIDSTANCE to HEELRISE: anterior calfband posterior directed force to knee extension
What happens when SET THE AFO in more DF?
if have recurvatum push tibia and fibula forward so not snap into extension —– posterior shell anterior directed force : for knee flexion
What happens when SET THE AFO in more PF?
if have buckling knee holds tibia and ibula back to not allow it to advance: create more extension at the knee
For RECURVATOM how should we set the AFO? DF or PF?
DF to move it slightly behind the knee joint (against extension)
Ground reaction orthosis
what it is
has a anterior shell on anterior of the proximal tibia
increase knee stability
AFO set in slight PF to increase extension moment for knee stability without needing a KAFO
indications:
- increase knee stability
- pediatrics (SP, spina bifida, TBI, SCI)
knee air splint
when it is used
training KAFO
fro buckling knee , used with a DF wrap (thighband of brace is 1.5 inch below the IT)
KAFO Checkout
- no proximal compression on IT, groin, or greater trochanter in sit or stand (ends 1.5 inch below IT)
- good anatomical and mechanical joint alignment–ankle level of medial malleoli and knee at level of DISTAL femoral condyles
- no skin pinching with movement
- relief for pressure sensitive areas
- secure and easy to operate straps and locks
- no pain or skin irritation: if redness do capillary refill test
Craig Scott Orthosis
it is a KAFO: (use in low thoracic SCI)
- stirrup shoe attachement, pre tibial and proximal femoral band **KNEE LOCK with CAM lock ***
- set ankle in DEGREES of DF
- stand with LORDOSIS and increased posterior pelvic tilt
- swing to /through gait /standing
HO
components 5
where do you put the hip joint align
after hip dislocate/THR
ALIGN MECHANICAL HIP 1/4 inch SUPERIOR AND 1/4 inch ANTERIOR OF GREATER TROCHANTER in order to put extension moment with weight line behind the joint
- pelvic band or jcaket
- lateral upright
- mechanical hip joint
- DIAL LOCK–can set range
- thigh shell –can prevent adduction
HKFO
what is it
lock hip jont to not have to stand in hyperextension
1, conventional vs okastc
- pelvic band or jacker
- lateral uprights
- mechanical joint 1/4 inch superior and 1/4 inch anterior to anatomical joint
- thigh bands
- stirrups
- stops/locks–usually DROP RING LOCK
RGO
what is it
reciprocal gait orthosis
HKFO with thoracolumbar extension to stabilize the spine (use with high SCI)
2-4 point gait for T4-L4 paraplegia (and swing to), it doesnt allow bilateral flexion
offset drop ring knee locks
molded thigh shell and solid AFO
can do with FES
REDUCED ENERGY EXPENDITURE
Exoskeletal orthosis
what is it
backpack power device so he can walk
Parapodium
what is it
pediatric HKFO to allow child to stand
–ROM, flexibility, WB through joints bone health…
hip and knee joints allow to sit , can use with swing to/through gait
NOT FOR RECIPROCAL GAIT
Indications for HKFO
- promote WB and standing in peds
- poor hip and trunk control
- control or prevent hip motions
- integrated with spinal orthotics
Specialized orthotics
fracture orthosis
peds braces: dennis brown splint, palvik harness, scottish rite
AFO Fracture Orthosis
where is the WB
is it eliminated
type of fracture and where
reduce WB through fracture site:
patella tendon bearing shelf to take weight off the shaft of the lower leg and take more weight proximally,
compression and total contact
reduce but not eliminate WB for mid/distal tiba fracture
comminuted fractuere
can have a patten bottom but then need a contralateral leg lift
. (note: it does not cross the knee joint)
KFAFO and HKFO fracture orthosis
where is WB
type of fx and where
where cannot it be used
1 Ischial shelf component—more pressure on the ischial tuberosity. Build an ishcial shelf into the brace to take the WB through the IT and take it away from distal femur. Use for a tibial plateau fracture. Redistribute weight away from the fracture site.
- Tibial plateau fractures* (used for these )
- Mid to distal femur fractures (cannot use with a proximal femoral fracture because too close with WB near fx site)
Dennis brown splint
i. Club foot / correct forefoot add & equinovarus (CTEV)—congenital talipes equinovarus
1. equinovarus : plantarflexion and inversion
ii. Abduction bar -on the brace to keep the feet separated
iii. Hinged shoes -can be rotated out to restore the normal tibial torsion
iv. Integrated with serial casting
1. Can be integrated with serial casting
2. But dennis brown splint allows you to rotate the feet out to try to restore the normal position—this is a brace that is correcting because of malleability in pediatric population
v. Tibial torsion abnormalities
Palvik Harness
i. For congenital hip dysplasia
ii. Poor hip joint congruency / stability
- For poor congruency between the femoral head and acetabulum
iii. Hold hips in abduction and flexion to maximize contact: femoral head in acetabulum
iv. Anterior straps to produce about 100 DEGREE FLEXION and posterior straps for ABDUCTION– To stabilize the femoral head in the acetabulum
Canvas straps between chest and feet
Children under 6 months of age –Used before the child is ambulatory
Rhino cruiser for ambulation if needed
Rhino cruiser
used for hip dysplasia when stand and ambulate
Scottish Rite Brace
i. For Legg Clave Perthes disease—AVN of the femoral head
ii. Loss of normal blood supply in young child
- Bone does not form correctly
- Misshapen femoral head
iii. Avascular necrosis of femoral head/ misshaped femoral head
iv. Pelvic band / movable hip joints / abducted thigh cuffs
- -It is like an HO with pelvic bands
- - Movable hip joints
- -ABDUCTED with thigh cuffs
v. Allows RECIPROCAL WB GAIT
vi. Integrated with surgical interventions
- -Usually multiple surgeries, not using the brace alone (ie brace after surgeries)
Orthotic donning:
which is in
supine ___
sitting __
SUPINE: HKFO, LSO, TLSO
SITTING: CO, CTO
why sit to don CO and CTO
CO & CTO don in sitting
Cervical orthosis, cervical thoracic orthoses put on usually in sitting
why supine to don HKFO, LSO, TLSO
HKAFO—usually don in supine (ie roll on side, brace put under them, then roll back onto brace)
LSO & TLSO in supine
Lumbar spine orthoses, thoracolumbar spine orthoses
In supine for good adjustment of the abdominal binder or the straps coming around the lower abdomen
Orthotic don considerations
a. Consider the need to remove the insole—for space inside the shoe
b. Can don shoe and brace together—the AFO can already be inside the shoe so can put them both on at once
c. Use a shoe horn with brace then shoe donning—can use the shoe horn to get on the shoe if put on the brace first
d. Secure closure of the shoe after maximal opening—putting on the sneaker widen it on all the way, the blucker opening, don’t want to crush the counter
e. For KAFO knee pad may need to be tightened in standing / and make sure the drop ring lock is engaged
Orthotic Checkout
—- Before application is it as prescribed: correct joints and suspensions
—- Check structural integrity and joint motion
Lock works
No broken pparts
Flex knee at least to 110 degrees – especially for sitting on lower surfaces
—- Can individual sit comfortably with feet flat on the floor
—- Check clearance for pressure sensitive areas
—- Check for good mechanical / anatomical joint congruency
—- Check for equal weight-bearing in standing
Can do the paper test
—- Check for balance in standing
—- Does brace stabilize or assist as indicated
—- Check for clearance of upright (about 1 cm)—make sure uprights don’t touch skin and that they wear long socks to protect their skin
—- Check for strap tightness—if put on straps do the finger test, if cannot get finger in the calf-band or thigh-band it is too tight, if slides in too easy it is too loose
—- Check skin integrity along with wearing schedule
Orthotic Considerations
—- Keep away from heat
especially for low temperature plastics, more so in hand and wrist splints
—- Keep away from sand / liquids
Interfere with joints and movement of the joints
—- inspect brace before donning
Make sure nothing sharp exposed
Make sure nothing in the shoe that shouldn’t be in there
—- Provide necessary cleaning and maintenance
—- Consider changes in girth
Issue with weight gain and loss
Keep away from heat
especially for low temperature plastics, more so in hand and wrist splints
—- Keep away from sand / liquids
interfere with joints and movement of the joints
—- Inspect brace before donning
Make sure nothing sharp exposed
Make sure nothing in the shoe that shouldn’t be in there
—- Provide necessary cleaning and maintenance
—- Consider changes in girth
Issue with weight gain and loss
Indication for Spinal Orthosis
—- Pain relief
—- Mechanical unloading
ie brace in extension to decrease loading on the anterior of the vertebrae
—- Spinal immobilization (post trauma / surgery)
Provide the R: rest
—- Management of compression fractures
especially in geriatric population (ie if anteriorly situated fracture can hold them in extension)
Scoliosis management
—- Kinesthetic reminder to avoid certain motions (ie soft collar)
Spinal Orthotic Considerations
- –Need good fit
- –Easy to don / doff
- –Provision for lines / tubes -If patient has a feeding tube or picc line there should be access to that
- –Access for wound care (surgical incision) -Be able to look at the suture line
- –Allow dissipation of heat / comfortable
Spinal orthotic drawbacks and precautions
—Atrophy with prolonged use (not using abs or back extensors as much
Hypermobility above and below
-See this with spinal fusions
Above and below the area stabilized get more mobility to compensate
—Osteopenia:Not allowing normal loading through the spine, loss of minerals in the bone
—Skin irritation / breakdown
especially if not fitted well
Do skin inspections
—Pulmonary compromise
TLSO restrict movement in lungs
Affect vital capacity, give deep breathing exercises, not too restrictive for normal expansion
—Cosmesis / compliance Not so pretty, very obvious
—Energy expenditure
Affect trunk movement/rotation this will affect overall gait and more energy expended
—ADL performance, Bending over and putting on shoes Gets in the way
Cervical Collar
how much reduce ROM
waht is it for
CO
Soft tissue trauma “whiplash”
CO is not used in fracture
Reminder
soft collar vs. rigid collar (does not really control AO joint at all, this is more for rest so healing can occur)
slight reduction in cervical movement by 10% in saggital plane
Rigid collar reduce cervical movement by 25% in saggital plane
Promote “R”: Rest for healing to occur
Warning to others
Higher profile HCO:
how much ROM reduced
when used
HCO:
philedelphia
miami J
65-70& ROM reduced!
use for
CERVICAL FUSION
DISECTOMY
Philadelphia
HCO: —foam material with a rigid exoskeleton (under chin and back portion up to occiput): it velcros
Higher profile HCO:
- –Reduce ROM 65%-70% (especially in sagittal plane)
- –Easy to put on – 2 components connected by Velcro on both sides
- – When it is used:
i. Following ant. Cervical fusions
ii. Discectomies
b. Miami J:
HCO: (“Aspen” Cervical Collar) higher profile—after cervical discetomy (remove disc) or fusion
Higher profile HCO:
- –Reduce ROM 65%-70% (especially in sagittal plane)
- –Easy to put on – 2 components connected by Velcro on both sides
- – When it is used:
i. Following ant. Cervical fusions
ii. Discectomies
SOMI
what is it
parts
indications (7)
HCTO: Sternal Occiputal Mandibular Immobilizer
HCTO: head cervical thoracic orthosis
Parts:
3 uprights: one anterior post & two posterior posts
Mandibular and occiput plates
Indications:
1) Mid cervical fractures
2) Step down from halo vest device
3) RA : in cervical area
4) DJD : in cervical area
5) Dens instability—odontoid process (if very severe would use a HALO)
6) Nerve impingement
Minerva Brace
HCTO: like SOMI but a little more controlling than the SOMI—provides more stabilization
HCTO: head cervical thoracic orthosis
Custom mold bi-valved with ant/ post plates
Anterior and inerscapular portion in back
Higher post profile for cervical extension control
Indications
1. Step down or alternative to halo vest device
2. Mid-cervical fractures
3. STABLE C1-C2 fractures
Don’t use for unstable C1/C2, it is ONLY FOR STABLE
HALO Vest
For maximum immobilization in cervical spine (mid high fractures)
—– Stabilization, so don’t get pressure in spinal cord
Good restriction in all planes
Parts
Cranial ring with skeletal attachment (4-6 pins)—put into the bone of the cranium
Attach to vest by 4 rods
Non-metal material ( For medical imagery testing)
Changes center of gravity—more of a challenge to work on sitting balance
Need to clean and adjust at pin sites
Also need to adjust if loosen
Need to do wound care around pin sites (benedine, tighten it, adjust it)
CASH: Cruciform Anterior Spinal Hyperextension
type of brace
purpose
indication
TLSO: thoracic lumbar sacral orthosis
PROMOTE EXTENSION : the brace is on the anterior of the body
- -Vertical bar and horizontal bar
- -Lightweight
Indication:
1) Low thoracic and high lumbar anterior COMPRESSION FRACTURES (T6-L1):
want to be in extension to take away compression on anterior portion of the vertebrae
—Take away anterior compression so want to be in extension
2) Osteoporosis: people with OA who are getting anterior compression fractures
Jewitt
what it does
indications
where it has pressure
TLSO: PROMOTE EXTENSION: Main force (T7/T8) on the posterior at the intrascapular pad: anteriorly directed force for extension
1) Thoracic and lumbar ANTERIOR COMPRESSION FRACTURE: T10-L3
2) Post-op STABILIZATION to keep in extension after surgery to prevent flexion: promotes extension
Promotes extension : pressure at the back mostly around T7/T8 in the intrascapular pad, then there is a counterforce anterior above and below)
Lateral uprights, 3 point pressure system: counter-forces above and below on the anterior : upper sternal pad and super pubic pad posteriorly directed force
ATLANTIC BODY JACKET
TLSO: common in the clinic
TLSO: thoracic lumbar sacral orthosis —–Molded plastic bi-valved
Indications:
1) *Post-op spinal fusions (anywhere between T7 to L4)
2) Muscle injuries
3) DJD
4) RA
5) Nerve Impingement
In documentations: write that it was intact and precautions were observed and maintained—we do not do a lot of ther-ex with these patients
Chairback:
type of brace
what motions it controls
LSO (lumbo sacral orthosis): primarily designed to stabilize in the lumbosacral spine, posterior uprights to control in saggital plane (uprights in back)
—flexion / extension
Knight
type of brace
what motions it controls
LSO: lateral uprights that gives control in sagittal plane and frontal plane control:
flexion / extension + lateral flexion + some rotation
- Post-operative and trauma bracing for thoracic, lumbosacral spine: these braces have abdominal binders that can be velcroed in front part
Taylor
type of brace
what motions it controls
TLSO brace extends up further to support thoracic spine: similar to atlantic and cash and Jewitt: if doesn’t give a lot of lateral support it is just a knight : control in saggital plane:
flexion/ extension
- Post-operative and trauma bracing for thoracic, lumbosacral spine: these braces have abdominal binders that can be velcroed in front part
Knight Taylor:
type of brace
what motions it controls
TLSO: frontal and saggital plane:
flexion/extension + lateral flexion + rotation
- Post-operative and trauma bracing for thoracic, lumbosacral spine: these braces have abdominal binders that can be velcroed in front part
Scoliosis Orthotics
— Prevent further progression
— Hold the curve and support the body
— Most commonly used for AIS (adolescence idiopathic scoliosis) during adolescence
Don’t always know the origin of it
Use in adolescence during growth spurts maybe age 12-18 years
— Worn 16 - 23 hours / day
– Some braces designed to be worn only at night: 8 hours / day (nocturnal
–Include correction pads—put pressure on ribs or spinous processes -
-Can be a
higher profile: CTLSO (Milwaukee):
or
shorter profile: TLSO (Boston brace)
Milwaki Brace
CTLSO for scoliosis: high profile
—–Apex of curve is above T6: this is a high profile brace
(If a low apex below T6 then you can use a lower profile scoliosis brace)
hold in posterior pelvic tilt creating a longitudinal force, there is some distraction longitudinal, it is not only a horizontal correction
Parts:
3 point pressure—pads on the uprights : 3 Uprights: 1 anterior upright 2 posterior uprights
Correction pads to control the scoliosis
Longitudinal distraction also!
. Lower profile scoliosis braces:
ie Boston Brace
TLSO: apex of the curve is below T6 a
TLSO
Spinecor dynamic brace—series of straps tighten for transverse and rotary forces
—Boston brace—lower profile scoliosis brace
Providence brace
—Wilmington brace
—Charleston brace
