Fourth Orthotics Mock Exam Flashcards
A patient is seen in clinic for a follow up appointment and is disappointed with the results of his custom solid AFO as he still has a pronounced knee hyperextension moment during stance phase of gait. You noticed this at his last follow up and had your technician add 1/4” heel lift to relatively dorsiflex the AFO to decrease the knee extension moment in stance. What should your first reaction be to this?
Check the durometer of the 1/4” heel lift your technician added.
Often times practitioners add a heel wedge to an SAFO to decrease knee hyperextention thrust but, the durometer of the heel wedge is most important as a soft heel wedge will cause ground reaction forces to remain anterior to the knee during loading response whereby increasing knee hyperextention. By utilizing a firm durometer for the heel wedge you can promote knee flexion. Note: check quadriceps strength prior to doing this as they must be able to control the flexion moment.
What all is found in the sartorius (femoral) triangle?
Femoral nerve, femoral artery, sartorius muscle and inquinal lymph nodes are all found within the scarpa’s triangle.
Note: Remember SAIL: Sartorius, adductor longus, inquinal ligament
A patient is seen in clinic, you are filling in for a sick practitioner whom delivered a KAFO 1 week earlier. The patient was provided the KAFO as he has 30 degrees genu recurvatum and 15 degrees fixed plantarflexion contracture. The patient states he has a hard time getting over his foot at midstance and that, while his knee extension is decreased, he feels excessive pressure on the posterior aspect of his knee. What adjustments or additions can you make to remedy this problem?
Add a 15 degree tapered heel wedge to the foot plate and add a contralateral heel lift.
By adding a 15 degree tapered heel wedge you will neutralize the KAFO in the sagittal plane allowing for a smoother rollover at midstance. It will also be necessary to add a contralateral shoe lift equal to the height of the tapered heel wedge to maintain a level pelvis as well as to assure proper clearance of the KAFO during swing phase of gait.
A patient is seen in clinic. The patient is utilizing foot orthotics with 3/8” heel lifts to decrease inflammation of her “achilles tendonitis”. What lumbar pathologies could this aggravate?
L5-S1 spondylolisthesis, DJD of the lumbar facet joints, lumbar spondylolsis.
When recommending heel lifts for achilles tendonitis recognize that it will increase lumbar lordosis. The listed lumbar pathologies are all treated by decreasing lumbar lordosis and can be aggravated by heel lifts on a relative scale.
You are seeing a patient with a diagnosis of peripheral vascular disease. What is the common artery that you can palpate to asses blood flow?
Dorsalis pedis.
Palpate the dorsalis pedis pulse along with capillary refill
What would you recommend for an addition to an articulated AFO for drop foot and posterior lateral hyperextension thrust of the knee (mild tone is present)?
PF stop will decrease drop foot in swing, 1/4” heel/lateral wedge will negate the posterior lateral knee extension thrust, and the metatarsal pad in combination with elevation of the 2nd-5th MTP’s and digits have been shown to decrease tone on a relative scale.
What additions can you make to an AFO to decrease excessive pronation within the AFO?
Extrinsic medial wedge, medial sabolich tab or trim line and/or sustentaculum tali “ST” pad
A patient has failed conservative treatment for plantar fasciitis including foot orthotics, physical therapy, shoe wear modification. What are the surgical interventions?
a. arthrodesis
b. ankle fusion
c. gastroc lengthening
d. plantar fascia release
e. a and b
f. c and d
g. All of the above
f. Gastroc lengething and plantar fascia release.
Ankle fusion and triple arthrodesis surgeries are not performed for plantar fasciitis. Usually treated arthritis with fusion of the calcanealcuboid, talonavicular, and talocalcaneal joints of the foot.
A patient is seen in clinic. She presents with severe chronic bilateral posterior tibialis tendon dysfunction “PTTD”. She has worn custom UCBL’s in the past but they were ineffective. What would be the most appropriate recommendation given her presentation and past?
An articulated AFO.
Given that UCBL’s were ineffective, articulated AFO’s would be appropriate as they grasp the lower legs and can help to modify internal tibial rotation. By decreasing internal tibial rotation, pronation will decrease whereby decreasing the work load of tibialis posterior muscle
A patient is seen in clinic whom has been diagnosed with guillain-barre syndrome. The patient has weak knee extensors, knee flexors, and ankle plantarflexors, and ankle dorsiflexors. What muscle groups would you expect to regain strength first if the syndrome begins to remit?
Knee extensors and flexors proximal to distal.
Having a patient perform a heel raise, screens what myotomal level?
S1, having a patient plantarflex is a screening technique for S1 myotome.
Often in the clinic a clinician will have a patient walk on their toes for S1 myotome screen and then walk on their heels for L4-5 screen
You have provided a patient with an articulated AFO and PF stop. When that patient ambulates you notice that they have pronounced knee flexion during loading response. What can cause this?
Firm extrinsic heel wedge, PF stop is too dorsiflexed. Both of these can cause ground reaction forces to translate posterior to the knee joint rapidly causing abrupt knee flexion during loading response
True or false, when designing a ground reaction AFO “GRAFO” foot plate, length can be full or sulcus length.
False, GRAFO’s tend to be fabricated with full foot plates so as to utilize a longer lever arm to resist knee instabilities throughout stance phase of gait
Damage to the femoral nerve will result in weakness of what main muscle group?
Knee extensors
The femoral nerve (L2, L3 and L4) innervates the quadriceps femoris muscle which serves to extend the knee. The hip extensors are innervated by the sciatic nerve. Hip abductors are innervated by the superior gluteal nerve. Ankle dorsiflexors are innervated by the tibial nerve
What describes the design of a GRAFO?
Trim lines for a GRAFO include Anterior/distal and posterior/proximal opening as well as posterior/distal and anterior/proximal areas of AFO contact. NOTE: it is important to make sure the patient can fit their foot and lower leg through the opening which tends to be narrow, but it is important to trim carefully so as not to lose the supportive structure of the GRAFO
True or False: a patient utilizing an articulated AFO with a full foot plate complains that it is hard to roll over their foot smoothly throughout stance. Recommending rocker sole shoe and or cutting the foot plate to sulcus length would be appropriate (assuming the have good knee stability in the sagittal plane)
True, sulcus length foot plates and rocker shoes can both contribute to a relatively smooth roll over in stance phase
True or false, the duration of double support varies inversely with the speed of walking and, in running, double support is absent.
True, in slow walking double support increase compared to the swing phase.
True or false, when fabricating a KAFO the distal/posterior thigh band and the proximal/posterior calf band should be located equidistant from the knee axis.
True, When fabricating a KAFO the distal/posterior thigh band and the proximal/posterior calf band should be located equidistant from knee axis so as not to impede knee flexion and soft tissue impingement in the popliteal fossa
A patient is seen in clinic. the patient is utilizing a KAFO for post polio syndrome. The ankle joint height is located correctly but the mechanical ankle joint is in need of replacement for the third time. What could cause this?
Tibial torsion was not build into the KAFO. If premature wear is notice in a KAFO ankle joint that is located at the proper height often times tibial torsion was not build into the othosis causing a lick of congruency between the anatomical and mechanical ankle joint
In normal gait, maximum knee flexion reaches approximately What degrees?
60 to 65 degrees, knee flexion durning swing phase in normal gait
When taking an impression and delineation for a KAFO what landmark represents knee enter?
The midpoint between medial tibial plateau and adductor tubercle. When taking and impression and delineation for a KAFO, knee center is represented by the midpoint between MTP and the adductor tubercle
Patellar tendon bearing AFO is indicated for which pathologies?
Charcot joint, avascular necrosis of the talus, osteoarthritis of the ankle joint, and calcaneal fracture are all pathologies potentially utilize a PTB AFO to un-weight the affected area during weight bearing
What is the primary function of brachioradialis?
elbow flexion, Brachioradialis muscle serves to flex the elbow
A KAFO patient is seen in clinic for follow up. The patient has utilize a KAFO for three years but has developed avascular necrosis “avn” of the femoral condyles. What change could you make to the current KAFO to allow for minimal ambulation with out slowing the reversal of AVN?
Incorporate ischial weight bearing. By fabricating an ischial weight bearing brim you can load proximally while unloading distally at the femoral condyles whereby allowing for minimal ambulation while treating AVN
True or false, an RGO allows forward progression by harnessing energy from one hip extension and translating it into contralateral hip flexion
True, by harnessing energy from one hip’s extension and translating it into contralateral hip flexion and RGO can facilitate forward progression
The radial nerve is injured within the radial groove. What muscle would not be paralyzed?
Triceps, the triceps muscle is innervated by the radial nerve, but when injury occurs at the radial groove usually it is just weakness not paralyzed. All the muscles in the posterior compartment will be paralyzed leading to wrist drop
When turning a conventional AFO into a dorsiflexion assist AFO, how would you set up double action ankle joint?
Springs in the posterior channel will produce dorsiflexion assist in double action ankle joint
A patient is seen in clinic with flaccid ankle plantarflexors and dorsiflexors. Choose appropriate double action joint configurations.
Pins in the anterior and posterior channels or springs in the posterior channels and pins in the anterior channels, both these configurations will provide anterior and posterior support for flaccid ankle plantarflexors and dorsiflexors
The claw hand appearance of the hand is due to damage to what nerve?
Ulnar nerve, Damage to the ulnar nerve commonly occurs where it passes posterior to the medial epicondyle on the humerus. The patient is likely to have difficulty making a fist due to paralysis of the intrinsic muscles of the hand. Claw hand comes from inability to flex the 4th and 5th MCP joint
The patient is seen in clinic with flaccid ankle plantarflexors and dorsiflexors. The patient also buckles at the knee during loading response/heel strike. You have choosen to recommend a conventional with double action ankle joint. What would be the most appropriate configuration of the ankle joints?
Springs in the posterior channels and pins in the anteriors channels. By having springs in the posterior channels and pins in anterior channels you will provide adequate anterior posterior support to the lower leg muscular imbalance but the posterior springs will allow controlled plantarflexsion during loading response whereby keeping the ground reaction forces anterior to the knee joint to decrease knee buckling
A patient with Duchennes muscular dystrophy is seen to ambulate with increased lumbar lordosis secondary to which muscular weakness?
Hip extensor. Individuals with duchennes muscular dystrophy often present with weakness of the hip extensors. By increasing lumbar lordosis the position of their center of mass is posterior to the hip joint which locks the hip against the Y-ligament allowing for stability in the sagittal plane.
A patient sustains a hangman fracture. This fracture can cause quadriplegia. What vertebrae and location of the fracture is damaged?
Atlas, lamina (pars interarticularis) C2. Hangman’s fracture occurs from fracture through the lamina of the axis. Another injury to the axis is displacement of the dens which may also cause quadriplegia
When designing a thermoplastic KAFO for a patient with severe genu recuravatum, what can you incorporate that will help control the knee hyperextension?
Extending the distal/posterior thigh trim lines more distally, decreasing the depth of the thigh section, extending the proximal posterior calf trim line proximally and decreasing the depth of the calf section. All of these design modifications will aid in decreaseing genu recurvatum
A patient wearing a KAFO is seen in clinic. The patient complains of anterior thigh pressure while sitting. What could be the cause?
the mechanical knee joint is too distal in relation to the anatomical joint. If the mechanical knee joint of a KAFO is too distal in relation to the anatomical joint the patient will experience pressure on the anterior portion of the thigh while sitting
The erector spine muscles are found in the intermediate layer of the muscle layers of the muscles in the back. When they act bilaterally, they extend the vertebral column. When they act unilaterally what action do they perform?
Laterally bend the vertebral column. The erector spine muscles act to extend the vertebral column and unilaterally act to laterally bend the column. Stabilize vertebrae durning local movements of the vertebral column is performed by the deep layer known as transversospinal muscles (multifidi, semispinalis, rotatores).
True or false. A child wearing a pavlic harness in treatment for congenital dislocation of the hips should have their hips oriented in flexion and adduction.
False, a child wearing a pavlic harness in treatment for congenital dislocation of the hips should have their hip oriented in flexion and abduction
A 240lb female bears how much weight collectively through her right 2nd-5th MTP joints while standing evenly on both feet.
40lbs, A 240lbs patient when standing evenly on both feet will have 120lbs on each foot. 50% goes through the calcaneus and 50% goes through the MTP joints. MTP’s 2-5 receive 66.6% of the total weight on the forefoot. .666X60lbs=40lbs
The axillary nerve innervates teres minor. What other muscles does it innervate?
Deltoid, axillary nerve also innervates the deltoid. At times there is injury to this nerve with shoulder dislocation
True or false, guillain-barre syndrome progresses in a ascending order.
True, Guillian-barre syndrome progresses in an ascending order “distal to proximal” and recovers in a descending order “proximal to distal”.
A child is seen in clinic. The child is playing on the floor and proceeds to use his hands to stand up by pushing off of his lower extremities until upright. What is the name of this maneuver and what diagnosis does this boy most likely have?
Gowers sign and duchennes muscular dystrophy. Duchennes muscular dystrophy is most common in you males and is characterized by the gowers sign “walking of the hands up lower extremities while standing” which is compensating for proximal lower extremity weakness
The lumbricals act to do what?
Flex the MP joints and extend the IP joint. Lumbrials act to flex the MP joint and extend IP joints. The interossei muscles act to either adduction or abduct the digits along with pairing with the lumbricals to flex the MC joints and extend the IP joint
When fabricating an AFO, the lateral proximal trim lines is located approximately 1 inch inferior to the fibular neck. What is the anatomical structure you are trying to avoid by doing this?
Common fibular nerve. The common fibular nerve “common peroneal nerve” runs just inferior to the fibular head superficially. Trim lines should be design to avoid impingement of this nerve when fabricating a AFO
The nominate bone of the pelvic girdle is known as what?
Sacrum. The pelvic girdle is mad up of the innominate bones of the iliums that articulate with the sacrum known as the nominate bone
The claw hand appearance is characterized by an injury to what nerve?
Ulnar nerve. Ulnar nerve injury will result in 4th and 5th MCP joints extended and IP joints of the same fingers are flexed
Injury to the medium nerve will result in what characteristic appearance when a patient tries to make a fist?
Ape hand and hand of benediction. Injury to the median may result in loss of opposition and flexion of the thumb resulting in the ape hand deformity. Also the of benediction results from injury of the median nerve at the elbow or upper arm.
At heel strike the knee joint is at ____ while the ankle joint is at_____.
At neutral/full extension, 90 degrees/neutral.
Trendeleburg gait can be seen in patients after they have total hip arthroplasty, injury to the superior gluteal nerve, and poliomyelitis. This is caused by weakness in what muscle?
Gluteus medius. Weakness of the gluteus medius results in trendelenburg gait. durning the stance phase the pelvis on the opposite side drops due to weakness on the stance side
A patient with C6 quadriplegia is able to use a tenodesis grip. What is the action that occurs?
Wrist extension which causes MP flexion. C6 quadriplegic patients functionally uses tenodesis grasp. This is caused by wrist extension which allows passive MP flexion
The deltoid muscle acts to abduct the shoulder with what other muscle?
Supraspinatus. Supraspinatus part of the rotator cuff assists with a abduction of the glenohumeral joint.
You are seeing a patient in acute rehab with a physical therapist. The patient has had a CVA. Upon examination you see foot drop durning gait, weak dorsiflexors grade 2, weak inversion and eversion grade 2, and increased tone in her plantar flexors. What would be an appropriate orthotic device?
A solid ankle AFO. A solid ankle AFO is indicated for a patient with drop who is also has spasticity as a spiral AFO and dorsiflexion assist AFO might increase her tone and are not sufficient to control spasticity.
A 16 year old patient has suffered an L2 complete spinal cord injury. What would be the most likely functional expectation and orthosis for this patient?
Ambulation with bilateral AFO’s and canes. A lesion at the level of L2 would be a lower motor neuron lesion as it is a cauda equina injury. You would expect that the patient would have intact hip flexion, hip adduction, and knee extension. This patient would only need AFO’s as bracing for the knee is not needed due to knee extension is still intact
Anterior displacement of the vertebral body on the lower vertebrae is called what?
Spondylolisthesis. Spondylolisthesis is described by the percentage of the anterior displacement of the vertebral body described by 4 grades (grade 1 0-25%, grade 2 25-50%, grade 3 50-75%, grade 4 75-100%) Spinal stenosis is the narrowing of the spinal column. Spondylosis is a term for osteoarthritis of the spinal column or neutral foramen. Spondylitis is inflammation of the vertebra
A 54 old female patient recently referred to your office for a KAFO style orthosis after several FTA (fail to appear) missing appointments for final fitting, you should what?
Call the prescribing physician and advise him that the device has yet to be fitted. The physician should be notified as they referred the patient to your office so hippa laws apply
When taking an impression for a KAFO, or the best possible impression, it is important to use the segmented impression procedure and what?
posterior popliteal rest. The posterior popliteal rest when properly positioned, helps to assure that correct positioning of the impression will help control recurvatum in the impression
Your office receives a telephone call from a lawyer’s office claiming to represent your patient Ms. couchkiller in her lawsuit with the local hospital. They are requesting a copy of her chart and are willing to pay you handsomely to send them overnight. You should reply to this request how?
Ask for the request in writing showing the signed release form of the patient for the information requested prior to complying with request. Hippa privacy law apply to all requests of personal information pertaining to the treatment or personal info
A visually impaired 70 year old male patient is referred to your office with a prescription for a HYPEREXTENSION back brace for an anterior thoracic compression fracture as a result of a fall at home. Upon PE, you find a male with marked kyphosis and significant arthritis of both hands. Your choice of orthotic devices should include…
Utilization of velcro for the closure to adapt to the patients arthritis. If the patient cannot donn the devise, the weight and ability to make adjustments are of no value to him
When evaluating a 14 year old female patient referred to your office with a prescription for a crouch gait orthosis. Upon observing her gait you are considering several styles of orthoses, they are…
custom molded floor reaction AFO with solid ankle and full footplates. The floor reaction design style includes an anterior pre-tibial shell to exert an anterior force keeping the knee in extension and controlling knee flexion. The solid ankle and full footplate help with the needed stability during all phases of gait.
During a follow up appointment with a 71 year old status post CVA patient who lives alone you fitted with a custom fabricated AFO with solid ankle and flexible full footplate PE reveals a reddened area on the tibial crest area. The patient denies any pain or discomfort, prior to scheduling for her 6 month follow up visit, you should what?
Add a hypo allergenic pad to the anterior velcro closure. By adding a hypo allergenic pad to the velcro strap you are distributing the pressure exerted on the anterior tibial area and making sure it is hypo allergenic and the patient denies pain or discomfort as well as the fact that she lives alone, you are assuring there will be no further pressure or skin issues with the patient. Additionally, you should schedule her for a follow up appointment sooner than 6 months to make sure that your remedy corrected the redness
True or False: When taking an impression for a dorsiflexion assist AFO, the patient’s optimum ankle foot position is in sub talar pronation forefoot neutral.
False, the optimum placement of the foot/ankle complex is sub talar neutral and when the patient is wearing appropriate footwear, the ankle should be 0 to 5 degrees of dorsiflexion to allow the foot to clear the floor
Mrs. Backscratch, a patient of Dr. Heart comes into your office and tells you that her friend was fitted with a lumbosacral support low back pain and that she tried ther corset on and it felt really good. You have and excellent working relationship with Dr. Heart, and you feel it will be ok with him for you to fit her with a corset similar to her friends. Are you correct in fitting he with device even though you do not have a prescription and plan on billing Mrs. Backscratch insurance company?
No, in order to submit a claim for third party reimbursement you must have a written, signed prescription from a physician. Also please not that it is good practice management to whenever possible, no matter how minor or simple you feel the device is to have a prescription for the dispensed device.
