Orthotics Flashcards
A force containing both direction and magnitude is called what?
A vector
The resultant force is a combination of what?
Two other vectors
The study of the path of motion is called…
Kinematics
The study of motion and the forces that produce it is called…
Kinetics
What is the name of a disease the presents as avascular necrosis of the femoral head?
Legg-Calve-Perthes disease
Who is most commonly affected by Legg-Calve-Perthes disease?
9-14 year old boys
Positioning the leg in what position can return the femoral head back into the acetabulum in Legg-Calve-Perthes disease?
Abduction and internal rotation
The difference between knee and ankle joint axis in the transverse plane is called what?
Tibial Torsion
What causes Charcot joint in the lower limb?
Neuropathic disease. Commonly diabetes. It is a progressive condition that involves the gradual weakening of bones, joints, and soft tissues of the foot or ankle.
The rapid, alternating involuntary movement elicited by a passive stretch in patients with spasticity is called what?
clonus
A patient presents with volar subluxation, ulnar deviation, and swan neck deformity in her fingers. What is a possible diagnosis?
Rhumatoid arthritis
A swan neck deformity presents as…
The PIP joints in hyperextension and the DIP joints are flexed.
Lateral epicondylitis is caused by what repetitive motion?
Repetitive extension of the wrist.
Carpel Tunnel Syndrome may result in numbness, tingling, and weakness in which part of the hand?
Thenar emminence, thumb, and digits 2 and 3.
The median nerve innervates which muscles of the hand?
- Lateral two lumbricals
- Opponens pollicis
- Abductor pollicis brevis
- Flexor pollicis brevis
True or False: A patient with a left sided CVA may experience right sided hemiplegia and aphasia.
True.
A child presents with a drooping eyelid, internal rotation of the shoulder, scapular winging, and and a flexion deformity of the wrist. What is a likely diagnosis for this child?
Erbs palsy
What is the etiology of Erbs Palsy?
It is an avulsion injury to the C5-C6 nerve roots of the brachial plexus caused most commonly during child birth from excessive pulling on the neck and head.
True or False: Guillian Barre is an infectious polyneuritis that leads to progressive muscular weakness that is usually fatal.
False: Prognosis is usually full recovery. Motor return is experienced proximally to distally.
A progressive neuromuscular atrophy characterized by weakness of the distal muscles of the arms and feet.
Charcot-Marie-Tooth Disease
True or False: Cerebral Palsy is the most common motor disability in children.
True
What is the most common type of Cerebral Palsy?
Spastic
How may a patient with spastic diplegia cerebral palsy present?
Muscle stiffness primarily in the legs with the upper extremities being less affected or not affected at all.
Tightness in the hip and leg muscles may result in a scissoring gait.
True or False: A child with spastic hemiplegia will generally present with more spasticity in the leg than the arm.
False: Those with spastic hemiplegia experience spasticity only on one side of the body and typically the arm is more affected.
True or False: CP patients with spastic quadriplegia will often have additional medical concerns such as intellectual disability and seizures.
True.
What movement patterns can you expect from a patient with Dyskinetic (athetoid) CP?
- Inability to control movement.
- Can present with low or high tone intermittently.
- The movements are uncontrollable and can be slow and writhing or rapid and jerky
Which type of CP results in primarily difficulty with balance and coordination?
Ataxic
Which ankle joint controls would be indicated for a patient with plantarflexion paralysis?
Dorsiflexion stop
A patient presents in gait with ankle in dorsiflexion, hips flexed, hyperlordosis, back extension and knees flexed. What type of gait is this?
Crouch gait
What population is crouch gait common among?
Cerebral Palsy
What are two reason an orthotist may not use a pretibial AFO to address crouch gait?
- Hip flexion contracture
- Lack of ankle range of motion
Contraindications for a floor reaction AFO.
- Genurecurvatum
- Coronal instability
A patient presents with 0/5 plantarflexion strength, 3/5 dorsiflexion strength and uncontrolled fluctuating edema. What type of brace would be appropriate for this patient?
Classic metal and leather with double action ankle joints.
A Sabolich trimline on an AFO is used to correct a varus deformity. Where should the three point pressure system be to correct the deformity?
- Medial aspect of the foot
- Lateral aspect of the ankle
- Medial aspect of the calf
A T-strap used for supination should be attached to which side bar?
Medial.
What is the minimal clearance for conventional ankle joints?
Lateral: 5 mm
Medial: 6 mm
Increasing the stiffness of a patients heel would have what effect on the knee at initial contact in a solid ankle AFO?
Increase knee flexion moment at heel strike.
In normal gait at heel strike, what angle is the knee in?
Complete extension (0)
In normal gait at heel strike, what angle is the hip in?
25-30 flexion
In normal gait at heel strike, what angle is the ankle in?
Neutral (90)
In normal gait at heel strike, where is the ground reaction force relative to the ankle and what moment is being executed in the joint?
- Posterior
- Plantarflexion
In normal gait at heel strike, where is the ground reaction force relative to the knee and what moment is being executed in the joint?
- Posterior
- Flexion
In normal gait at heel strike, where is the ground reaction force relative to the hip and what moment is being executed in the joint?
- Anterior
- Flexion
In normal gait at loading response, what angle is the hip in?
25-30 degrees
In normal gait at loading response, what angle is the knee in?
20 degrees of flexion
In normal gait at loading response what angle is the ankle in?
8 degrees of plantarflexion
In normal gait at loading response, where is the ground reaction force relative to the hip and what moment is being executed in the joint?
- Anterior
- Flexion
When is peak contraction of the knee extensors being fired during a normal gait cycle?
Loading response
When does peak dorsiflexion take place during normal gait?
Terminal stance
How far does the center of gravity shift vertically during ambulation?
2 inches
Where is the center of gravity located on the human body?
Anterior to the 2nd sacral bone
At what point during normal gait does the center of gravity reach its apex?
Midstance
A patient presents in your clinic with a dispensing prescription for a wrist hand orthosis. The patient has no volitional control of the thumb. Which component should be added to the WHO to control the thumb?
Thumb post.
A patient presents in your clinic with a shoulder subluxation secondary to hemiplegia. What orthotic option would best relieve pain and reduce further subluxation?
Hemisling or should subluxation splint.
A patient presents with C6 quadrilegia. Which muscle group can be used for prehension on a wrist-driven WHO?
The extensor muscles of the wrist.
- Extensor carpi radialis
- Extensor carpi longus
- Extensor carpi brevis
A ratchet type tenodesis orthosis with a locking mechanicsm would benefit what type of patient?
One who does not have volitional control to maintain prehension.
Which nerve would be damage in a patient who would benefit from a wrist extension orthosis?
Radial nerve
What is a colles fracture?
A fracture of the distal radius caused by wrist extension and radial deviation.
How would you treat a mid-humeral fracture with a radial nerve lesion?
Humeral fracture brace with a positional cock up wrist splint and sling.
What is a smith fracture?
A fracture of the distal radius caused by falling on a flexed wrist.
Which type of hip dislocation is more common, anterior or posterior?
Posterior
What is the MOI for a posterior hip dislocation?
Hip flexion, adduction, and internal rotation.
A patient presents with a prescription for a hip abduction brace following a posterior hip dislocation. The physician states “set to standard ROM”. What range of motion do you set the brace in?
- Abduction fixed at 15 degrees.
- Hip flexion set to 0-60 degrees.
What is the standard ROM for a hip abduction brace following an anterior hip dislocation?
- Abduction fixed at 20 degrees
- Extension blocked at 20 degrees of flexion.
A patient presents with a thickened nodule and band in the palmar aponeurosis of his 4th and 5th digit. What is the name of the associated pathology?
Dupuytrens Contracture
At which degree of burn does a patient become insensate?
3rd degree (full thickness) burn
A patient has experienced a 2nd degree burn, what signs and symptoms would you expect to see?
Redness, blistering, and pain.
What are the most common orthoses used following a rotator cuff tear?
Slings and Airplane SEWHOs
What is the ideal placement of an MP stop?
Just distal to the MP joints.
What position is the hand in when it is in “functional position”?
30 degrees of extension at wrist
35-40 degrees of MP flexion
15 degrees of DIP flexion
Thumb opposed with webspace maintained.
List the purpose of a functional static orthosis.
Enables ADLs while being worn. Maintains webspace and three point prehension.
What is the benefit of a dorsal style WHO orthosis?
Allows volume fluctuation
A patient presents with a boxers fracture. Which bone may be broken and what style orthosis would be the most appropriate?
- Most commonly the 5th metacarpal.
- Ulnar gutter splint
What are the four goals of a hand orthosis?
- Maintains palmar arch
- Maintains opposition
- Maintains webspace
- Attachment site for components
An aluminum style hand orthosis that is easily contoured and acts as an attachment sight for components is called a…
Rancho style
A patient presents with a median nerve injury with resulting injury to the abductor pollicis brevis. What component of a WHO would best benefit the patients presentation?
An adductor stop (c-bar) to increase webspace.
A finger driven dynamic WHO is best indicated for someone who presents in what way?
Weakened MP extension, full active flexion of at least one finger of the hand.
A wrist-driven tenodesis WHO is best indicated for a patient with lesions of what nerve roots?
C6-C7.
Extension strength must be a grade 3+ or higher.
A ratchet style WHO is best indicated for patients with lesions at what nerve roots?
C5.
Indicated for patients with wrist extension strength less than grade 3.
A patient presents with ulnar clawhand deformity. What components of a WHO are best indicated for this patient?
- MCP extension stop to decrease MCP hyperextension. (Loss of lumbricals and interossi)
- IP extension assist
- 1st dorsal interosseous assist
A patient presents with a C8-T1 lesion. What presentation would you expect to see?
Complete loss of opposition and intrinsic muscles of the hand. Wrist control would remain entirely intact.
What two muscles would be the strongest inverters of the foot in the open chain?
Tibialis anterior and posterior.
True or False: The gastrocnemius and soleus are weak inverters of the foot.
True. The gastroc and soleus insert medial to the subtalar joint axis.
The anterior compartment of the lower limb is innervated by what nerve?
Deep fibular (peroneal) nerve
What is the benefit of a calf lacer on an AFO?
Axial unloading and unweighting of the foot and ankle.
What is the minimum amount of relative dorsiflexion an individual requires in order to benefit from an articulated AFO?
10 degrees
During preswing, what must occur at the knee to insure foot clearance?
Passive knee flexion to 40 degrees.
Double limb support accounts for what percent of the gait cycle?
20%
A patient presents with flexible equinovarus during swing phase and forefoot initial contact. Which nerve may be damaged?
Common fibular nerve
What is the purpose of the spring ligament?
- Connects the calcaneus to the navicular
- Supports the talus.
Which ligament prevents excessive eversion of the ankle?
The deltoid ligament
True or False: A negative windlass mechanism may be a sign of down-syndrome.
True
At which joint does plantarflexion and dorsiflexion occur?
Chopart and talocrural joint
Peak plantarflexion occurs at what stage of the gait cycle?
Toe-0ff/Preswing
Inversion and eversion occur at what joint?
Subtalar joint
What degrees of total range of motion is considered functional at the subtalar joint?
10 degrees
In what position is the foot the most stable?
Supination.
- Talocrural plantarflexion
- Hindfoot inversion
- Forefoot adduction
What percentage of axial loading does the tibia bear?
83%
The lateral compartment of the lower extremity consists of the fibularis longus and brevis which are innervated by what nerve?
Superficial fibular nerve
The posterior tibialis muscle and flexors of the toes lie in which compartment of the lower extremity? Which nerve innervates them?
- Deep posterior compartment
- Tibial Nerve
Muscular dystrophy is defines as
a symmetrical progressive degeneration of fibers.
At what level of thoracic fracture would the use of shoulder straps be indicated to add additional control in a TLSO.
A fracture superior to T4.
TLSO indicated for fractures at what levels?
T4-L3
LSO indicated for fractures at what levels?
L1-L3
LSO posterior superior trimline should end where?
10 mm inferior to the inferior angle of the scapulae
LSO posterior inferior trimline should end where?
Sacral coccygeal junction
LSO lateral inferior trimline should end where?
10 mm above the trochanteric clearance
TLSO and LSO anterior inferior trimline should end where?
10 mm superior to the pubis symphysis with enough clearance for the rectus femoris musculature.
TLSO and LSO anterior superior trimline should end where?
10 mm inferior to the xyphoid process
A chairback LSO provides control in which planes?
Sagittal (flexion and extension) only
A Knight LSO provides control in which planes?
Sagittal and coronal
The Taylor TLSO provides control in which planes?
Sagittal only
The Taylor-Knight brace controls movement in which planes?
Sagittal and coronal planes
A custom body jacket controls movement in which planes?
All planes
The Jewett or CASH orthosis is used for what type of spinal injury?
Anterior column compression fractures
What is the primary purpose of using a TLSO for neuromuscular scoliosis?
- Providing comfortable trunk support
- Increases breathing, independence, and use of extremities.
What are three diagnoses that may present with neuromuscular scoliosis?
- Muscular dystrophy
- Spinal muscular atrophy
- Poliomyelitis
Single column, multiple level fractures are considered stable or unstable?
Stable!
A boney, three column horizontal fracture in which all ligaments are intact is called a ______ fracture. True or false: This fracture requires surgical intervention?
- Chance fracture
- False. As long as the ligaments are intact, this injury has a good prognosis when treated conservatively with a custom TLSO.
True or False: An unstable odontoid fracture can be treated with a SOMI CTLSO?
False. An unstable odontoid fracture requires a HALO vest, traction, or surgery.
Boys peak growth takes place at approximately what age? Girls?
Boys: approximately 14 years old
Girls: approximately 12 years old
A rib-vertebral angle difference (RVAD) of greater than what degree is considered to be progressive?
Greater than 20 degrees
When treating infantile scoliosis, which is more important to treat - rotation or curve?
Rotation is more important.
What is the age range for infantile scoliosis? Juvenile? Adolescent?
Infantile - 0-3 years
Juvenile - 4-10 years
Adolescent - 10-18 years
At what degrees of curvature is orthotic intervention indicated in adolescent scoliosis?
20-45 degrees
A Milwaukee style CTLSO is indicated for a curve with an apex above at which level?
Apex of C7 or above.
Daytime wear orthoses are more effective at treating what type of curves than nighttime braces (charleston/providence)?
Double and single thoracic curves. Comparable results for single thoracolumbar and lumbar curves.
True or False: A Monteggia fracture is a fracture to the proximal ulna with a radial head dislocation and can be treated with a tightly fitting forearm cast.
False. Must be treated surgically as a cast will not maintain the reduction of the radius.
What percent of load goes through the medial column of the foot?
70%
The peroneus longus tendon travels under the _____ bone and inserts at the ______.
- Cuboid
- 1st metatarsal
What is the name of an autoimmune disorder that affects the neuromuscular junction and results in weak/ineffective gait?
Myasthenia Gravis
True or false: Spina bifida effects both motor and sensory nerves leading weakness as well as inability to sense the position of the lower limb?
True.
A lesion at the sacral level will affect primarily which muscles?
The gastroc-soleus complex predominantly. Hip abductors and extensors also weakly affected.
A lesion at the L4/L5 level will affect which muscles?
- Sacral level (gastroc-soleus), hamstrings, intrinsic foot muscles.
- Present with excessive DF and knee flexion
- Crouch gait.
A lesion at L3 will affect which muscles of the lower extremity?
- All included effected below level of L3 as well as the quadriceps.
- KAFO intervention often indicated.
Lack of selective motor control is consistent with an upper motor neuron lesion or lower motor neuron lesion?
Upper. Muscles cannot be isolated and often there is a synergy pattern present.
The extensor synergy pattern presents as hip ______, knee ______ and ankle ______.
Extension, extension, plantarflexion.
The flexor synergy pattern presents as hip _______, knee ______, ankle _______.
Flexion, flexion, dorsiflexion.
What adjustment can be made to the footplate of a solid ankle AFO to decrease extension moment at the knee?
Cut back to 3/4/metatarsal length.
What is the ideal plastic selection for most pediatric AFO implementation?
3/32 polypro
What is the benefit of using a posterior offset knee joint on a KAFO?
- Mechanical joint is posterior to the anatomical joint which increases stability.
- Encourages weight-line to pass anterior to the mechanical joint.
Which knee joint allows for adjustable flexion ranges?
dial lock
A patient with knee weakness and instability has difficulty going from sit to stand. What knee joint would self lock as the knee gains more extension to increase stability?
Ratchet (step) lock
True or False: A patient with a spinal cord injury at L3 should be fit with bilateral KAFO’s and forearm crutches for standing.
False. At this level a standing frame, parapodium, or RGO is indicated.
How can a patient with T12 paraplegia utilizing bilateral KAFO’s achieve stance?
With the ankles set into relative dorsiflexion - the weight line progresses posterior to the hip and the Y ligament maintains stability.
A patient presents with genu recurvatum and PF contracture. What would the best joints be to increase knee stability?
Posterior offset
A patient presents in your clinic for a KAFO deliver. Once she is fit, you determine that she is hyperextending inside of the brace. What adjustment to the KAFO can best reduce the hyperextension?
decrease the depth of the distal thigh band.
A new patient with a transtibial amputation presents in you clinic. They tell you that the have been diagnosed with chronic kidney disease as well as diabetes mellitus. What are a couple concerns you will need to be aware of during the management and education of this patient?
- Likely to have volume fluctuations due to kidney disease. Manage expectations of sock-ply management, skin concerns, and regular follow-ups.
- Casting appointments should take place when patient is at their highest volume (usually the afternoon before they have dialysis).
Comorbidities that can effect volume levels.
- Congestive heart failure
- Diabetes mellitis
- Chronic kidney disease
- Cancer (esp if going through radiation)
- DVT
Which two curve types are more likely to progress in patients with AIS?
Single thoracic and double curves.
What are three contraindications for orthotic management of AIS?
- Angle greater than 45 or less than 20
- Risser 4 or higher
- Thoracic lordosis
A physician asks you to fit a CASH brace to a 74 year old female with osteoarthritis of the thoracic spine at T6-T8. What is your next step?
- A CASH brace is indicated for compression fractures and has free extension.
- Speak with the physician and recommend a TLSO that will better help help the patient (such as one with sagittal and coronal control).
Which ligaments are contained within the posterior column of the spinal cord?
Capsular ligament, ligamentum flavum, infraspinalis, and supraspinalis
At what apical vertebral level is a CTLSO indicated?
Apex higher than T8.
This pathology is defined as a narrowing of the central or lateral canal of the spinal column.
Spinal Stenosis
What is the structure affected first with degenerative disk disease?
Nucleus Pulpulous
What is the name of a hyperextension injury of C2 leading to a fracture?
Hangmans fracture
What grades of spondylolisthesis can be managed orthotically?
Grade 1 and 2.
What is the minimally accepted curve correction found on an in-brace xray.
50%
In what plan is a burst fracture the most unstable?
Transverse
At which spinal level (specific) is the most sagittal motion present?
C0-C1
How should pins be tightened during HALO fitting?
Diagonally opposed pins tightened at the same time.
A 17 year old patient diagnosed with L4 spondylolysis is referred to your clinic for an LSO How should the stays be contoured to achieve optimal outcomes and decrease pain?
Straight
A patient diagnosed with AIS has a single apical vertebrae at T12. What type of curve pattern is this considered?
Thoracolumbar
A young woman is seen in your clinic diagnosed with AIS. She is a good candidate for orthotic a management, but presents with 10 degrees of thoracic kyphosis. Which component would you add to address her thoracic alignment?
Extend the posterior superior trimline to the level of T3 with “rabbit ears”
Typically, how many months after menarche does a young woman have until she reaches skeletal maturity?
18
A young female presents in your clinic for the first time. Her initial x-ray reveals a curve of 22 degrees with an apical vertebra of T9. She has a Risser sign of 2. What is the best course of treatment?
Observation until progression is proved.
At what anatomical structure should the window opposite a thoracic curve terminate superiorly?
Off the superior rib of the apical vertebra
On which side should a trochanteric extension be?
The side of decompensation.
A long C-curve is most indicative of what type of scoliosis?
Neuromuscular
At what degree of curvature is surgery indicated in patients with Scheurmanns Kyphosis?
80 and above
Where should the pads be placed on a CTLSO for treating Scheurmanns Kyphosis?
Posterior to the apex of the curve
What degree of toe-out is considered typical?
7 degrees
What distance distal from the fibular head should the AFO portion of a KAFO terminate?
25mm
Typical locked KAFO gait is achieved by what gait deviations?
Hip-hiking and circumduction
At what degree of genurecurvatum is a AFO indicated?
<30 degrees of recurvatum
True or False: Double action ankle joints allow for the greatest degree of adjustability out of all traditional joints?
True
True or false: A varus T-strap wraps around the lateral bar and will keep the medial malleolus off of the medial side bar.
False: A varus t-strap will keep the lateral malleolus off of the lateral sidebar.
True or False: A flange on the medial portion of an AFO with distal forces will correct a valgus deformity.
False: it will correct a varus deformity
What effects does a full foot plate AFO have on the knee
Extension at the knee
A patient presents with quadricep weakness of 2+/3 out of 5 and instability at the foot and ankle. What two orthotic interventions are indicated for the presentation of quadricep weakness?
- Ground reaction AFO (better if knee instability is absent)
- KAFO (better if knee instability is present)
List indications for a KAFO in the sagittal plane, coronal plane, and transverse plane.
Sagittal Plane: Quad strength 3+ or less, genurecurvatum of 30 degrees or greater, flexion contracture.
Coronal Plane: medial or lateral instability
Transverse: rotational instability (combined instability)
Which knee joint would be used when there is coronal plane instability alone?
Straight free motion joints
Which knee joint is beneficial for patients with recurvatum?
Posterior offset
A patient with paraplegia presents in your clinic for bilateral KAFO’s. The patients goal is to stand independently with the KAFOs donned. What is the optimal alignment of the ankle in order to allow the patient to achieve this goal?
The ankles should be aligned in dorsiflexion so that KAFOs are located anteriorly to the body weight line. This will allow the patient to achieve standing by placing the weight line posterior to the hip joint and the patient can achieve standing by relying on the Y ligament for stability at the hip.
What hip orthosis maintains the leg in 45 degrees of hip abduction and 90-100 degrees of flexion? What condition is this used to treat?
- Pavlik Harness
- Hip dysplasia
What orthosis is used for patients with Legg-Calve-Perthes in order to maintain the hip in abduction and internal rotation?
Scottish Rite Hip Orthosis
What is the main biomechanical principle implemented in the use of a Sarmiento Brace for non-operative treatment of fractures?
Soft-Tissue compression
Where is the callus formation on a patient with ankle equinus and excessive dorsal 1st ray translation?
2nd and 3rd MTP
Which muscle during stance phase rotates and locks the cuboid on the calcaneus?
Fibularis longus
