P&O

Question 1

A 6 year-old boy undergoes a transtibial amputation for a malignant bone tumor in his distal tibia and is fitted with a below-knee prosthesis. At his current age, how often can his prothesis be replaced?

Answer 1

Every 18 months
- Until age 5, a prosthetic device should be replaced annually. From age 5-12, a prosthetic device can be replaced every 18 months. A prosthetic device can be replaced every 2 years from age 12-21.

Question 2

A 25 year-old male is brought by ambulance to the emergency department after he was an unrestrained driver in a motor vehicle accident. He is awake, alert, and answering questions upon arrival. He complains of severe pain in his neck and is unable to move his lower extremities; he is able to flex his elbows and extend his wrists bilaterally against resistance, but he has 0/5 strength in elbow extension, finger flexion, and finger abduction. He is found to have an ASIA A spinal cord injury that corresponds with his motor level. He does not gain any further motor function during his acute hospitalization or acute rehabilitation stay compared to his initial emergency department physical exam. What orthosis may promote improved functionality of his upper extremities?

Answer 2

Tenodesis splint
- This patient has a C6 SCI and we are told the grading is ASIA A. The mechanism of his SCI is an MVA, which is the most common cause of SCI overall and for his age group. Patients with C6 tetraplegia may benefit from a tenodesis orthosis, which utilizes the patient’s ability to extend their wrist to induce passive finger flexion and hand-grasp. This allows patients to hold objects even though they lack the muscle activation required for finger function. An opponens orthosis is used to immobilize the thumb to allow for healing of various musculoskeletal injuries. A flail arm splint is used after brachial plexus injuries. A SEWHO can be used if there is some degree of remaining elbow flexion to allow a patient to feed themselves.

Question 3

Which of the following sentences describes a K0 ambulator?

Answer 3

Nonambulatory
-Medicare’s K levels are defined as follows. K0: nonambulatory - “K0 = zero prosthesis”. K1: limited household ambulator at a fixed cadence. K2: unlimited household ambulator and limited community ambulator at a fixed cadence. K3: unlimited community ambulator with a variable cadence. K4: high impact sports activities, unlimited community ambulation, variable cadence.

Question 4

A 65-year-old previously retired businessman with uncontrolled diabetes (hemoglobin A1C 12%) has developed significant radiating pain down his distal right forearm into his 5th finger. He notices this pain is worse when he flexes his right elbow. The patient is right-handed. EMG/NCS shows severe ulnar neuropathy at the level of the elbow. An orthopedic surgeon recommends against surgery until his diabetes is better controlled and refers the patient to you for further treatment options. What bracing would be most appropriate?

Answer 4

Long arm splint
- The most appropriate bracing option for ulnar neuropathy at the elbow is a long arm splint which functions to keep the elbow in 45 degrees flexion. This helps to prevent impingement at the cubital tunnel which would reproduce the patient’s symptoms. A flail arm splint is used after brachial plexus injuries. An ulnar gutter splint immobilizes the 4th and 5th fingers, often to allow for healing after 4th/5th metacarpal or phalange fractures. A thumb spica splint limits thumb ROM, and can be used for DeQuervain tenosynovitis, skier’s thumb, distal 2/3 scaphoid fractures, and 1st CMC arthritis.

Question 5

Which of the following will assist dorsiflexion of an ankle-foot orthosis (AFO)?

Answer 5

Spring placed in the posterior channel
- In an AFO, a pin placed in the anterior channel will prevent dorsiflexion. A spring in the anterior channel will assist plantarflexion (will not prevent dorsiflexion, but will assist the opposite movement - plantarflexion). A pin in the posterior channel will prevent plantarflexion. A spring in the posterior channel will assist dorsiflexion.

Question 6

Which of the following motions activates a body-powered upper extremity terminal device?

Answer 6

Humeral flexion and scapular abduction
- An upper limb body-powered prosthesis is activated with biscapular abduction and humeral flexion, which first flexes the elbow into place, then the elbow position is locked into place with biscapular depression and humeral extension, and then this sequence is repeated to open and close the terminal device.

Question 7

In preparation for the residual limb to accept a prosthesis, which of the following is the ideal shape of the residual limb following a transfemoral amputation?

Answer 7

Conical
- Cylindrical is the ideal shape for a transtibial residual limb. Conical is the ideal shape of a transfemoral residual limb.

Question 8

You are analyzing the gait of a 46 year-old female who is status-post right transtibial amputation. She has acquired her definitive prosthesis, which involves a locking pin suspension system, polycentric knee unit, and multiaxis foot. As she walks down the hallway, you attempt to detect if any gait abnormalities are present. Which of the following would be expected to cause an excessive prosthetic knee extension moment?

Answer 8

Excessive plantarflexion built into the prosthetic foot
- Factors that would be expected to cause excessive prosthetic knee unit extension include: too much friction built into knee unit; too much plantarflexion in the foot, weak quadriceps (causing genu recurvatum), socket placed too far posteriorly; foot placed too far anteriorly. Factors that cause excessive prosthetic knee flexion include: not enough friction built into the knee unit; too much dorsiflexion in the foot; weak quadriceps; socket placed too far anteriorly; foot placed too far posteriorly; knee flexion contracture.

Question 9

A 41 year-old male presents for ongoing skilled rehabilitation following a motor vehicle accident. As a result of this trauma, he is status-post left transtibial amputation. During his first 2 weeks of physical therapy, he improves his hip and knee range of motion to expected full range. He has full strength in bilateral lower extremities where limb is intact. You determine that he will likely require a prosthesis that will allow him to function as an unlimited community ambulator with a variable cadence in his gait. Which of the following best describes this patient’s expected K-level of ambulation?

Answer 9

K3
- K levels describe how functional of an ambulator a patient is projected to be K0 = nonambulatory - “zero prosthesis” K1 = limited household ambulator, fixed cadence K2 = unlimited household; limited community ambulator; fixed cadence K3 = unlimited community ambulator, variable cadence K4 = high impact activities; sports, variable cadence

Question 10

In a Chopart amputation, which of the following bones is spared?

Answer 10

A Chopart amputation is an amputation that removes all foot bones except tibia, fibula, and talus. A Lisfranc amputation is a pre-metatarsal foot amputation (sparing all bones proximal to the foot metatarsals). A Boyd amputation is is a horizontal amputation through the calcaneus. A Pirogoff amputation is a vertical amputation through the calcaneus. A Syme amputation spares the tibia, fibula, and calcaneal fat pad (all other bones are removed).

Question 11

A 78-year-old male presents for acute inpatient rehabilitation after a C7 spinal cord injury. As a result of his injury, he demonstrates preserved shoulder abduction, elbow flexion, and wrist extension. He exhibits very limited grip strength, however, and often cannot grasp objects. Which upper extremity orthosis may benefit this patient functionally?

Answer 11

Tenodesis splint
- This patient would benefit from a tenodesis splint which uses preserved wrist extension to help approximate thumb and fingers passively to allow for a pinch. If wrist extension is preserved but finger flexion is nonfunctional, a tenodesis splint can be functionally beneficial. A Bobath splint provides resting hand position to limit hand spasticity/contracture. A carpal tunnel splint provides a relatively neutral wrist position to decrease stress on the median nerve as it traverses the carpal tunnel. A short opponens splint is used for thumb pathologies.

Question 12

Which of the following orthoses would be most appropriate for an unstable bony fracture at C4?

Answer 12

Halo vest
- The halo vest and Minerva jacket are the appropriate orthoses for use in unstable cervical spine fractures. The philadelphia collar and SOMI are useful for stable cervical spine fractures. The Knight-Taylor brace is a thoracolumbosacral orthosis (TLSO) and not useful for cervical spine fractures.

Question 13

Which of the following is the most common cause of upper extremity amputation?

Answer 13

Trauma
- Trauma is the most common cause of upper limb amputation; dysvascular disease due to hypertension, diabetes, factor 5 leiden mutation, etc.) is the most common cause of lower limb amputation.

Question 14

Which of the following is NOT a typical component of a lower extremity prosthesis prescription?

Answer 14

Lower extremity prosthesis prescription components include the socket, suspension, knee unit (if applicable), pylon/shank, and foot unit.

Question 15

You examine a patient’s gait following right transfemoral prosthesis fitting. During ambulation the patient’s left foot plantarflexes excessively during left leg stance phase, vaulting the right lower limb above the ground as it advances through swing phase. Which of the following is a potential cause of this gait abnormality (vaulting on the right side)?

Answer 15

Of the answer choices, only excessive knee friction would result in a straight limb which, unable to flex at the knee and clear the foot from the ground, must result in being vaulted up into the air (or perhaps circumducted) in order to clear the ground. A prosthesis being too long, not too short, could also cause vaulting. A prosthetic foot set too far laterally would cause a valgus knee moment. Excessive foot dorsiflexion would cause excessive knee flexion, not extension as observed in this patient.

Question 16

A horizontal amputation through the calcaneus is better known by which of the following names?

Answer 16

A Boyd amputation is is a horizontal amputation through the calcaneus. A Pirogoff amputation is a vertical amputation through the calcaneus. A Syme amputation spares the tibia, fibula, and calcaneal fat pad (all other bones are removed). A Chopart amputation is an amputation that removes all foot bones except tibia, fibula, and talus. A Lisfranc amputation is a pre-metatarsal foot amputation (sparing all bones proximal to the foot metatarsals).

Question 17

Which of the following will assist plantarflexion of an ankle-foot orthosis (AFO)?

Answer 17

Spring placed in the anterior channel
- In an AFO, a pin placed in the anterior channel will prevent dorsiflexion. A spring in the anterior channel will assist plantarflexion (will not prevent dorsiflexion, but will assist the opposite movement - plantarflexion). A pin in the posterior channel will prevent plantarflexion. A spring in the posterior channel will assist dorsiflexion.

Question 18

A 34 year-old male who is status-post right transfemoral amputation secondary to motor vehicle accident presents to you on rounds. He is wearing his postoperative residual limb shrinker as directed. He tells you that it feels as if his right foot is still present. Which of the following terms best describes this?

Answer 18

A Phantom sensation
- Phantom sensation is common after limb amputation, and is described as the persistent nonpainful sensation/feeling that the amputated portion of the affected extremity is still present (that the patient can still feel it, even though it is no longer attached to their body).

Question 19

Which of the following will prevent plantarflexion of an ankle-foot orthosis (AFO)?

Answer 19

Pin placed in the posterior channel

Question 20

A 17-year-old football player is the local high school’s star running back. In the 2nd game of the season, he attempts to make a cut on a planted right foot. He feels a ”pop” in his right knee and his leg gives out. He has immediate pain and swelling in his right knee and is unable to bear weight on that leg. MRI of the right knee the following day reveals a tear of his ACL (anterior cruciate ligament) and he undergoes surgical reconstruction. Which of the following orthoses is most appropriate post-operatively?

Answer 20

Lenox-Hill derotation orthosis
- Following ACL reconstruction, a Lenox-Hill derotation orthosis is often used to control axial rotation of the knee as well as medial-lateral and anterior-posterior control.

Question 21

Which of the following braces is most appropriate for a patient with severe plantarflexion spasticity? AFO: ankle-foot orthosis. KAFO: knee-ankle-foot orthosis.

Answer 21

Rigid AFO
- A rigid AFO is also called a solid AFO, and prevents any motion at all of the ankle and foot; this is most useful in cases of severe spasticity that needs to be controlled more firmly with a rigid orthosis. PLS and semirigid AFOs are more useful if severe spasticity is not present, as the spasticity will inappropriately overpower these orthoses. A KAFO is useful in cases of impaired muscular control of the knee and ankle, not the ankle alone.

Question 22

In an amputation surgery, which of the following surgical techniques is most appropriate in patients with severe dysvascular disease?

Answer 22

Myoplasty involves suturing the muscles to each other, and is technically easier. Myodesis involves suturing the muscles into the bone, produces a more stable surgical result, but is contraindicated in patients with severe dysvascular disease, as it will not heal properly due to the poor blood supply.

Question 23

You see a 72 year-old male with CAD, atrial fibrillation, COPD, PAD, HTN, uncontrolled DM2, CKD stage IV, and metastatic lung cancer who presents with bilateral knee pain. His pain is described as aching and worst over the medial aspect of both knees. He denies mechanical symptoms and he does not have any signs of an inflammatory process on exam. He has no signs of ligamentous injury on exam. Gait examination reveals no significant abnormality other than antalgic gait during stance phase bilaterally. Knee radiographs reveal significant subchondral sclerosis, joint space narrowing, and osteophytes primarily located within the medial compartments of bilateral knees. He asks for treatment options, but he states he doesn’t want to try any medications or injections given his complex medical history and he adamantly refuses surgery of any type due to complications from prior surgical interventions. What would be the most reasonable treatment of the options listed?

Answer 23

Lateral heel wedge

Question 23

A baby is born with a left transradial limb deficiency. The parents question whether phantom limb pain will be a concern for the baby, as the baby’s grandfather has significant phantom limb pain in the setting of a transtibial amputation due to uncontrolled diabetes mellitus. Which of the following is the most appropriate response?

Answer 23

Phantom limb pain is uncommon in cases of congenital limb deficiency
-The rate of phantom limb pain is significantly lower in congenital limb deficiency compared to acquired amputation. For acquired amputations, the rate of phantom limb pain generally increases with age

Question 24

At your skilled nursing facility you decide to follow up on a 71 year-old male who is status-post right transtibial amputation. This patient has been making steady functional gains in physical and occupational therapy. He currently requires minimum assistance for transfers. You have been thinking lately about a future lower extremity prosthesis for this patient. You expect him to ultimately function at the level of a K1 ambulator. Which of the following correctly describes K1 ambulation function?

Answer 24

Limited household ambulator, fixed cadence
- K levels describe how functional of an ambulator a patient is projected to be K0 = nonambulatory - “zero prosthesis” K1 = limited household ambulator, fixed cadence K2 = unlimited household; limited community ambulator; fixed cadence K3 = unlimited community ambulator, variable cadence K4 = high impact activities; sports, variable cadence

Question 25

A 57 year-old female presents for follow-up after receiving her definitive left transtibial prosthesis. She has been undergoing prosthetic gait training at your facility. Today she tells you that her left distal residual limb has been hurting while she ambulates using her prosthesis. She denies numbness or tingling. On physical examination, you detect red and firm skin at the distal residual limb. You diagnose venous choke syndrome. Which of the following is the most likely cause of this presentation in this patient?

Answer 25

The socket is too tight
- Too tight of a prosthetic socket can cause venous choke syndrome: impaired venous outflow in the residual limb due to an ill-fitting (too tight) socket constricting blood flow; this can lead to red and firm/indurated skin at the residual limb. If left untreated, verrucous hyperplasia (warts) and venous stasis ulcers may develop. Treatment involves improving socket fit by adjusting sock ply or by fabricating a new total-contact fit socket.

Question 26

A very active 52 year-old is competing in his first triathlon. The swim portion of the race takes place in the Atlantic Ocean, and he unfortunately is bitten in the right lower extremity by a shark which necessitates a right transfemoral amputation due to significant neurovascular trauma. He successfully undergoes the amputation and is subsequently fitted for an ischial containment socket 4 months later after the incision is healed and edema is controlled. Which of the following is not a typical component of an ischial containment socket?

Answer 26

Maintains slight abduction and extended position of the hip
- An ischial containment socket is the typical preferred socket following transfemoral amputation. Weight is borne by the ischium. This is a wide A-P and narrow mediolateral diameter socket. The usual positioning is slight hip adduction and flexion; this positioning places the hip abductors and hip extensors in a mild stretch which is mechanically advantageous.

Question 26

At what age should the first prosthesis be fitted in a child with otherwise normal development who has a congenital left lower extremity deficiency?

Answer 26

9 months
- In a child with a congenital unilateral lower extremity deficiency, the first prosthetic fitting should occur when a child is able to pull to stand, which typically occurs around the 9-10 months of age. The first lower extremity prosthetic is typically jointless.

Question 27

Which of the following is the correct method by which a myoelectric prosthesis causes activation of the terminal device?

Answer 27

Surface electrodes respond to intact muscle belly activation by sending signals to terminal device
- With a myoelectric prosthesis, surface electrodes are placed over intact muscle bellies and respond to the activation of these muscle bellies by sending signals to the terminal device when these muscle bellies are activated voluntarily. For example, surface electrodes placed over the wrist flexor group will respond to wrist flexor activation by causing the terminal device to close.

Question 28

Which of the following sentences describes a K3 ambulator?

Answer 28

Limited community ambulation at a fixed cadence
- Medicare’s K levels are defined as follows. K0: nonambulatory - “K0 = zero prosthesis”. K1: limited household ambulator at a fixed cadence. K2: unlimited household ambulator and limited community ambulator at a fixed cadence. K3: unlimited community ambulator with a variable cadence. K4: high impact sports activities, unlimited community ambulation, variable cadence.

Question 29

Which of the following is the most common activation method for an upper limb body-powered terminal device of a prosthesis?

Answer 29

Voluntary opening
- The most common activation method for an upper limb body-powered terminal device is voluntary opening. The terminal device remains closed at rest (safer than open at rest), and only by force from the patient does the terminal device open and allow the patient to grasp something. Voluntary closing is the opposite, and is less common. Proximity opening/closing is not a method.

Question 30

Regarding pediatric prosthetics, approximately how often should a left transradial prosthesis be prescribed between ages 14 and 20?

Answer 30

Every 2 years
- Between ages 0-5 the prosthesis should be replaced approximately annually. Between ages 5-12 the prosthesis should be replaced approximately every 18 months. Between ages 12-21 the prosthesis should be replaced approximately every 2 years.

Question 31

A foot amputation that involves removing the metatarsals and all bones distal to them is also known by which of the following names?

Answer 31

A Lisfranc
- A Lisfranc amputation is a pre-metatarsal foot amputation (sparing all bones proximal to the foot metatarsals). A Boyd amputation is is a horizontal amputation through the calcaneus. A Pirogoff amputation is a vertical amputation through the calcaneus. A Syme amputation spares the tibia, fibula, and calcaneal fat pad (all other bones are removed). A Chopart amputation is an amputation that removes all foot bones except tibia, fibula, and talus.

Question 32

You are discussing your patient’s new knee-ankle-foot orthosis (KAFO) with the patient’s orthotist. She mentions that she intentionally offset the KAFO’s hinge joint to sit posterior to the patient’s knee. Which of the following is the most likely purpose of offsetting the hinge posterior to the patient’s knee?

Answer 32

to cause the line of gravity to fall anterior to the knee
-Offsetting the hinge joint of a KAFO serves the purpose of moving the line of gravity anterior to the patient’s knee, which then tends to lock the knee in extension, producing a stable knee during ambulation that locks appropriately and will not buckle. This is useful in patients with weak quadriceps (not spastic quadriceps) who need extra assistance in extending/locking the knee during ambulation. Promoting knee flexion would occur if the hinge were fixed anteriorly to the patient’s knee.

Question 33

A 21-year-old basketball player attempts to catch a pass from his teammate but drops the ball and immediately experiences pain in his distal third digit. Instant replay shows the basketball hitting his third fingertip causing a forced flexion moment at the DIP. He is taken out of the game and seen by the team physician; during initial examination, the patient is unable to actively extend the DIP of his third finger. Xrays are negative for acute fracture. What splint is most appropriate to promote proper healing of his injury?

Answer 33

Stax splint
- The vignette describes a mallet finger injury, which is often seen in sports such as basketball or baseball. Typically, a ball hits the distal aspect of a finger, causing flexion of the DIP and resultant extensor tendon rupture. This leads to inability to actively extend the DIP. X-rays are appropriate to rule out avulsion fracture. A stax splint or DIP extension splint is appropriate to allow for healing of the DIP extensor tendon. A swan-neck ring splint and Boutonniere ring splint are examples of static-motion blocking splints that are used to treat their respective namesake. A resting hand splint promotes ROM of joints of the hand to avoid contracture formation, typically after stroke.

Question 34

A patient with a traumatic bilateral transtibial amputation status post bilateral transtibial prostheses would be expected to ambulate with which of the following energy costs of ambulation above normal?

Answer 34

40% above normal
- Energy costs of ambulation as a percentage above normal values for various traumatic amputation levels are as follows: Unilateral transtibial amputation: 20%. Bilateral transtibial: 40%. Unilateral transfemoral: 60%. Bilateral transfemoral: 200%. These values are approximations and will vary depending on the patient.

Question 35

A baby is born with a left transradial limb deficiency. There was no prenatal care for mother or baby prior to uncomplicated vaginal delivery. While hospitalized postpartum, the PM&R team is consulted to assist with appropriate care regarding the limb deficiency. When should the first fitting for prosthesis occur for upper limb deficiency?

Answer 35

6 months of age
- The baby in the question stem has a left transradial limb deficiency, which is the most common congenital limb deficiency. When the child develops sitting balance, which occurs around 6-7 months old on average, the first prosthesis fitting should occur. The first prosthesis is generally a passive mitt; later, around 12 months of age, a more complex prosthesis can be fabricated which can allow for grasp and release. The answer choice of 2 months of age would be prior to achievement of sitting balance and therefore the prosthesis would be much less beneficial. The answer choice of 24 months of age would be much later than desired and would not allow for optimization of functional use of the upper extremity and prosthesis. In general for prosthetic fitting in congenital limb deficiencies, the fitting should occur at appropriate times correlating with typical developmental milestones.

Question 36

A 7-year-old child undergoes a right transtibial amputation for a mangled limb after his leg was caught underneath a push lawnmower. What is the most common complication following an acquired amputation in a child?

Answer 36

Terminal overgrowth
- In a child with an acquired amputation, terminal overgrowth at the transected end of a long bone is the most common complication. This typically requires surgical revision. For this reason, disarticulations are often considered in growing children when determining the level of amputation; disarticulations maintain the growth centers of long bones in a growing child. The other complications are possible but not as common as terminal overgrowth. In general, the risk of phantom limb pain following amputation is decreased with younger age.

Question 37

In a prosthesis, the socket should exhibit which of the following characteristics?

Answer 37

Total contact fit
- Total contact fit is important for every socket prescription; without total residual limb contact with the socket interior, the patient risks having skin breakdown, venous choke points, warts, and other abnormal limb problems.

Question 38

When prescribing and fabricating a lower extremity prosthesis, it is important to keep in mind pressure-tolerant areas of the lower extremity. Which of the following is NOT a pressure-tolerant area?

Answer 38

Lateral tibial plateau
- Pressure-tolerant areas of the lower extremity include: Patellar tendon, medial tibial flare, medial tibial shaft, anterior tibial muscles, fibular shaft, popliteal fossa.

Question 39

In preparation for the residual limb to accept a prosthesis, which of the following is the ideal shape of the residual limb following a transtibial amputation?

Answer 39

Cylindrical is the ideal shape for a transtibial residual limb. Conical is the ideal shape of a transfemoral residual limb.

Question 40

A vertical amputation through the calcaneus is better known by which of the following names?

Answer 40

A Pirogoff amputation is a vertical amputation through the calcaneus. A Boyd amputation is is a horizontal amputation through the calcaneus. A Syme amputation spares the tibia, fibula, and calcaneal fat pad (all other bones are removed). A Chopart amputation is an amputation that removes all foot bones except tibia, fibula, and talus. A Lisfranc amputation is a pre-metatarsal foot amputation (sparing all bones proximal to the foot metatarsals).

Question 41

Regarding a transtibial prosthesis, all of the following are pressure-tolerant areas except which?

Answer 41

Fibular head
- Pressure-tolerant areas include the patellar tendon, medial tibial flare, medial tibial shaft, anterior tibial muscles, fibular shaft, and popliteal fossa.

Question 42

Regarding socket dimensions, which of the following socket designs is generally preferred for transfemoral amputation patients receiving a prosthesis?

Answer 42

Narrow mediolateral
- The ischial containment socket is preferred for transfemoral amputees. This involves a socket that is narrow in the mediolateral plane and wider in the anteroposterior plane; weight is borne by the ischia. The quadrilateral socket has wide mediolateral dimensions and narrow anteroposterior dimensions.

Question 43

Which of the following is the most common type of amputation?

Answer 43

Transmetatarsal

Question 44

A patient with a traumatic unilateral transfemoral amputation status post transfemoral prosthesis would be expected to ambulate with which of the following energy costs of ambulation above normal?

Answer 44

60% above normal
- Energy costs of ambulation as a percentage above normal values for various traumatic amputation levels are as follows: Unilateral transtibial amputation: 20%. Bilateral transtibial: 40%. Unilateral transfemoral: 60%. Bilateral transfemoral: 200%. These values are approximations and will vary depending on the patient.

Question 45

Which of the following is the primary advantage of prescribing a prosthetic socket with a total contact fit?

Answer 45

Reduced risk of venous choking
- The primary reason for prescribing a total contact socket is so that the residual limb remains healthy. If the distal part of the residual limb is not in contact with the socket wall, then the distal limb venous return is at risk for being choked off, leading to pain, skin breakdown, and other abnormal skin changes.

Question 46

A 67-year-old male with a history of cervical spondylosis presents with right hand paresthesias. His internist orders an EMG/NCS of his right upper extremity, which reveals absent median nerve SNAP (sensory nerve action potential) and positive sharp waves in the APB (abductor pollicis brevis) muscle during the needle exam. He undergoes surgical treatment. Following surgery, which of the following orthoses is most appropriate?

Answer 46

he patient has right hand paresthesias in the setting of severe median neuropathy findings on EMG (absent median nerve SNAP and active denervation of APB (PSWs)) which indicates median neuropathy as the likely diagnosis. The most appropriate surgical intervention would be carpal tunnel release given the severity of the disease based on electrodiagnostic findings. Following carpal tunnel release, a gel shell splint is used; this is a nonarticular brace (doesn’t cross joint meaning it doesn’t restrict ROM) used to help prevent hypertrophy of the surgical scar by maintaining pressure against the healing incision. A thumb spica splint limits thumb ROM, and can be used for DeQuervain tenosynovitis, skier’s thumb, distal 2/3 scaphoid fractures, and 1st CMC arthritis.

Question 47

Regarding limb amputation, in general, which of the following applies?

Answer 47

The longer the residual limb, the better the patient’s function
- The longer the residual limb, the more functional a patient can be with that limb (for example, comparing a shoulder disarticulation with a transmetacarpal amputation). The shorter the limb, the higher the cost of ambulation, and the more likely cancer was involved as the reason for amputation.

Question 48

Which of the following orthoses would be most appropriate in the setting of a type 2 dens fracture?

Answer 48

Minerva jacket
- The halo vest and Minerva jacket are the appropriate orthoses for use in unstable cervical spine fractures, such as a type 2 dens fracture. The philadelphia collar is useful for stable cervical spine fractures. The Jewett brace is a thoracolumbosacral orthosis (TLSO) and not useful for cervical spine fractures.

Question 49

A frail 80 year-old female with PMH of significant knee osteoarthritis which limits her ambulation presents to your outpatient clinic with mid-low back pain for the past month. She denies known trauma or inciting event. She has no radicular symptoms, denies bowel and bladder dysfunction, and denies saddle anesthesia. She has point tenderness over the thoracolumbar junction in the midline, and her pain is increased with lumbar flexion. X-ray reveals the suspected diagnosis. What brace would be least indicated?

Answer 49

Milwaukee brace
- From the vignette the most likely diagnosis is vertebral compression fracture. She is an elderly woman who is described as frail, with limited ambulation due to significant knee OA which would make her prone to osteopenic changes. Compression fractures are very common at the thoracolumbar junction, and typically cause anterior wedge deformities which worsen patient’s pain when they assume a lumbar flexion position. Stable compression fractures are often treated without bracing which can cause disuse atrophy of core musculature. However, when bracing is indicated, appropriate choices include Taylor brace, CASH brace, or Jewett brace. A Milwaukee brace is a CTLSO (cervical-thoracic-lumbar-sacral orthosis) most often used for scoliosis.

Question 50

Which of the following will prevent dorsiflexion of an ankle-foot orthosis (AFO)?

Answer 50

In an AFO, a pin placed in the anterior channel will prevent dorsiflexion. A spring in the anterior channel will assist plantarflexion (will not prevent dorsiflexion, but will assist the opposite movement - plantarflexion). A pin in the posterior channel will prevent plantarflexion. A spring in the posterior channel will assist dorsiflexion.

Question 51

Which of the following may result in a prosthetic limb exhibiting excessive knee extension during ambulation?

Answer 51

Too little friction in the prosthetic knee
- Of the answer choices, only a too-anterior foot would cause excessive knee extension, by forcing the line of gravity to tend to extend the knee. An anterior socket, excessive dorsiflexion, and too little knee friction would all cause knee flexion moments.

Question 52

A 77 year-old male undergoes a transfer during physical therapy and complains of sudden-onset severe low back pain. X-rays diagnose a T10 vertebral body compression fracture. Which of the following bracing recommendations is most appropriate?

Answer 52

CASH brace
- In cases of vertebral body compression fracture, CASH (cruciform anterior spinal hyperextension) or Jewett braces are recommended in order to maintain a neutral (non-flexed) spine position to prevent worsening of the compression fracture via hyperflexion forces. A soft lumbar corset will not provide sufficient stabilizing force to resist spine flexion. A flexion-biased brace is the opposite of what is indicated in these patients. Bracing is not contraindicated in these cases (quite the opposite, as discussed!).

Question 53

Which of the following is an advantage of elbow disarticulation over transradial amputation?

Answer 53

Surgery is easier and less bloody
- The main advantage of elbow disarticulation over transradial amputation is that surgery is easier and less bloody. Prehabilitation is always very important for every type of amputation. Transradial amputation results in easier prosthesis fitting and more pronation and supination preserved than elbow disarticulation.

Question 54

You are rounding on an 82 year-old female with a past medical history of uncontrolled diabetes mellitus with severe physical deconditioning secondary to multiple bouts of pneumonia. She is status-post right transtibial amputation due to complications from diabetes. She asks you which type of lower extremity prosthesis you are planning to prescribe for her. You are of the opinion that she will remain nonambulatory for the rest of her life. Which of the following best describes her K-level of ambulation?

Answer 54

K0
- K levels describe how functional of an ambulator a patient is projected to be K0 = nonambulatory - “zero prosthesis” K1 = limited household ambulator, fixed cadence K2 = unlimited household; limited community ambulator; fixed cadence K3 = unlimited community ambulator, variable cadence K4 = high impact activities; sports, variable cadence

Question 55

Which of the following orthoses would be most appropriate for a patient with 27 degrees of thoracic scoliosis?

Answer 55

Milwaukee brace
- The Milwaukee brace is essentially a cervicothoracolumbosacral orthosis (CTLSO) whose function is to correct a scoliotic curve by maintaining postural control of essentially the entire spine. It must be worn at all times, except for bathing, and is typically indicated for a scoliotic curve between 20-40 degrees. The Jewett and Knight-Taylor braces are TLSOs that are most useful in preventing thoracic hyperflexion, notably after suffering from a vertebral body compression fracture. The Minerva jacket is useful in cases of unstable cervical spine fractures, not scoliosis.

Question 57

An otherwise healthy 6 year-old boy complains of pain in the groin that extends distally into his medial thigh and medial knee. Imaging reveals avascular necrosis of the femoral head. After orthopedic consultation, physical therapy, reduced weight bearing, and bracing are recommended. In what position should the hip be placed?

Answer 57

Externally rotated, hyperabduction
- The likely diagnosis of avascular necrosis (AVN) of the hip in a child age 4-10 is Legg-Calve Perthes disease. This refers to idiopathic AVN of the femoral head in children. It often presents as hip pain that may radiate into the ipsilateral thigh/ or knee. The goal of bracing, when indicated, is to promote a hip position that places the femoral head completely within the acetabulum; this is attained with external rotation and hyperabduction.

Question 58

Which of the following amputee K levels describes a patient who is capable of unlimited household ambulation and limited community ambulation at a fixed cadence?

Answer 58

K2
- Medicare’s K levels are defined as follows. K0: nonambulatory - “K0 = zero prosthesis”. K1: limited household ambulator at a fixed cadence. K2: unlimited household ambulator and limited community ambulator at a fixed cadence. K3: unlimited community ambulator with a variable cadence. K4: high impact sports activities, unlimited community ambulation, variable cadence.

Question 59

In a patient with a congenital terminal left transradial limb deficiency, which of the following points in time would be most appropriate to first prescribe a prosthesis?

Answer 59

6 months
- 6 months is when an upper limb prosthesis might be first prescribed, and approximately 9 months is typical for the first lower limb prosthesis prescription (when the child is pulling to stand).