Prosthetics week 1B

What does TLSO stand for?

Thoraco-lumbar-sacral orthosis.

What does LSO stand for?

Lumbar-sacral orthosis.

What does AFO stand for?

Ankle-foot orthosis.

What does KAFO stand for?

Knee-ankle-foot orthosis.

Primary purposes of spinal orthoses

Limit range of motion, decrease spinal loading, and support unstable injuries.

Typical duration of spinal orthosis use during healing

Approximately 12 weeks.

Normal spinal curvatures

Lumbar lordosis, thoracic kyphosis, and a small cervical lordosis.

Primary functions of the spine

Allows multiplanar movement, tolerates axial loading, and protects the spinal cord.

Anterior spinal column structures

Anterior vertebral body, anterior annulus fibrosus, and anterior longitudinal ligament.

Middle spinal column structures

Posterior longitudinal ligament, posterior annulus fibrosus, and posterior vertebral body.

Posterior spinal column structures

Posterior vertebral arch, supraspinous/interspinous ligaments, facet joints, and ligamentum flavum.

When is a spinal fracture unstable (three-column concept)?

When two contiguous columns or all three columns are affected.

What is a compression fracture?

A fracture typically affecting the anterior column, common in osteoporosis.

When does a compression fracture become unstable?

When approximately 50% of vertebral body height is lost.

Difference between a burst fracture and a compression fracture

Burst fractures affect anterior and middle columns; compression typically affects only the anterior column.

Three-point pressure principle definition

One primary force at the target area with two opposing counterforces above and below.

Three-point pressure principle in scoliosis bracing

Force applied at curve convexity with counterforces applied at concavity.

Three-point pressure principle in an AFO

Posterior shell and footplate supply moments; shoe supplies counterforce at dorsal foot.

Three-point pressure principle in a finger splint

Extension moment at PIP joint with counterforces at DIP and MCP joints.

Role of the three-column concept in orthosis selection

Identifies injury stability; multi-column injuries may require orthotic support.

Short-term vs. longer-term orthotic use

Short-term supports active healing; longer-term restricts motion or reminds patient.

How the three-point pressure principle restricts movement

Opposing primary force and counterforces create moments that limit unwanted motion.

What are the indications for a Halo vest, and how does it stabilize the cervical spine?

A Halo vest is used to stabilize the occipitocervical spine and control axial motion at this level. It is secured with 6-8 transcranial pins connected by rods to a thoracic vest. It restricts movement and may also provide a degree of distraction. It is indicated for higher cervical fractures and dislocations, either postoperatively or for conservative fracture management.

What are two functional limitations a patient may experience when wearing a Halo vest?

The Halo vest can change the person's center of mass and affect balance. It also limits downward gaze, making it difficult to see step heights, changes in the walking surface, or changes in surface grade. An assistive device is often used to improve walking safety.

What is the primary purpose of a soft cervical collar, and how much movement does it restrict?

A soft collar primarily provides comfort and support rather than significant immobilization. It limits cervical mobility by approximately 10-15%, mostly at the extremes of flexion due to contact with the material.

What conditions may indicate the use of a soft cervical collar?

A soft collar may be used for soft tissue injuries, such as minor whiplash, as well as spondylosis or postoperatively when the spine is completely stable.

What are the characteristics and indications of an Aspen collar?

The Aspen collar is a prefabricated, semi-rigid cervical collar with a plastic exterior and foam-padded liner. It uses the sternum, clavicles, trapezius, and upper thoracic spine for inferior control, while the occiput and mandible provide superior control. It may be used after cervical fusion or laminectomy, or for conservative management requiring nonoperative immobilization.

Why does the Aspen collar have an open anterior shell?

The open anterior shell allows access for ventilatory equipment.

How does the Philadelphia collar compare with the Aspen collar?

The Philadelphia collar has the same indications and uses the same superior and inferior points of control as the Aspen collar. However, it is made entirely of foam and does not have a removable liner, making it harder to clean and typically limiting its use to the short term.

What are the characteristics and indications of a Miami J collar?

The Miami J is a commonly used prefabricated, semi-rigid cervical collar with a plastic external shell and removable foam lining. It is used for postoperative stabilization following cervical fusion or laminectomy and for conservative, nonoperative management of more stable fractures.

What is one advantage of the Miami J collar compared with the Aspen and Philadelphia collars?

The Miami J has been shown to provide improved cervical range-of-motion restriction compared with the Aspen and Philadelphia collars. Its removable foam lining also makes cleaning easier, and patients typically have two liners so one can be worn while the other is being cleaned.

What are the indications and characteristics of the NecLoc collar?

The NecLoc is very similar to the Miami J and has the same indications. Although manufacturers claim that it provides improved cervical range-of-motion restriction, studies have not entirely supported that claim.

What factors often determine whether a Miami J, Aspen, Philadelphia, or NecLoc collar is used?

The choice is often determined by physician preference or the institution's purchasing preferences rather than major differences in indications.

What is the primary indication for a Headmaster collar?

The Headmaster collar is indicated for head drop associated with neck muscle weakness. It may be useful for patients who cannot tolerate a soft collar that makes full contact around the neck, including some patients followed in an ALS clinic.

What are the characteristics of the Headmaster collar?

The Headmaster collar is lightweight, prefabricated, and available in various sizes. Sizing is based on the distance from the chin to the sternum.

Why might a Headmaster collar be better tolerated than a soft cervical collar for some patients?

It is very lightweight and does not require the same full contact around the neck as a soft collar, which may be uncomfortable or poorly tolerated by patients with neck muscle weakness.

How do the indications for a Halo vest, soft collar, semi-rigid cervical collars, and Headmaster collar differ?

- Halo vest: Stabilizes the occipitocervical spine for higher cervical fractures and dislocations.

- Soft collar: Provides comfort and support with minimal immobilization.

- Aspen, Philadelphia, Miami J, and NecLoc: Provide semi-rigid cervical stabilization, often after cervical fusion or laminectomy or for conservative management, depending on the injury.

- Headmaster collar: Supports the head in patients with neck muscle weakness and head drop.

What are the primary indications for cervical-thoracic orthoses (CTOs)?

CTOs support treatment of the upper cervical spine, including C3-C7, and the upper thoracic spine.

What are the extended Miami J and Minerva CTO, and how do they provide stabilization?

They extend into the thoracic region. Minerva CTO better immobilizes higher cervical regions like C1 and C2.

Which movements does the Minerva CTO restrict, and when is a Halo preferred?

Restricts flexion, extension, axial rotation, and lateral bending. Halo is preferred for full occipitocervical restriction.

Why is the upper thoracic spine difficult to immobilize?

It is a transition region between the mobile cervical spine and the rigid thoracic spine.

What is the SOMI brace, and what are its indications?

Sternal-occipital-mandibular immobilizer used for lower cervical/thoracic spine down to T5, often non-surgically.

What are the primary risk factors or conditions associated with thoracic vertebral compression fractures?

Osteoporosis is primary; metastatic disease and multiple myeloma are also associated.

What are the potential benefits and limitations of orthotic intervention for osteoporosis?

Use over 6 months may improve postural control and strength, reducing pain/kyphosis, though compliance is vital.

What is the primary goal of bracing for an active vertebral compression fracture?

Pain relief rather than direct management of the fracture.

What are the Jewett and CASH braces, and what is their primary purpose?

Braces for compression fractures that limit anterior flexion and encourage thoracic extension to unload the column.

For which fractures are Jewett and CASH braces indicated, and how are they fitted?

Indicated for lower thoracic/upper lumbar fractures; custom-fitted to position the patient in slight hyperextension.

How does the principle of flexible versus fixed range of motion apply when fitting a Jewett or CASH brace?

The brace influences posture only within flexible ROM, optimizing extension where available.

What are the indications for a thoracolumbosacral orthosis (TLSO)?

Thoracic or lumbar spine fractures, conservative/nonsurgical or postoperative management, and spinal cord injuries.

How are TLSOs constructed, and how do they immobilize the spine?

Custom-molded thermoplastic with thoracic straps; immobilizes through total contact and compression.

How does a tightly fitted TLSO help unload the vertebral bodies?

Increases intracavitary pressure, which unloads vertebral bodies while providing immobilization.

What are the purposes and limitations of a lumbar corset?

Reduces gross trunk motion and increases intracavitary pressure, but provides limited resistance to gross body movement.

What does the evidence say about the effectiveness of lumbar corsets for low back pain?

Evidence is questionable with no proven prevention/management benefit, though risks are low so they are still used.

How does a sacral orthosis or pelvic belt work, and where should it be positioned?

Applies compressive force across the pelvis to stabilize SI joint; positioned just proximal to greater trochanter.

When are sacral orthoses or pelvic belts commonly used?

Commonly used for pregnancy-related sacral pain associated with ligamentous laxity.

What are the indications for a lumbosacral-thoracic orthosis with a hip spica component?

Immobilization of lower lumbar spine/hip joint, lumbar/sacral fractures, proximal hip fractures, or hip dislocation.

What hip flexion range is generally allowed with a hip spica component, and how does this affect function?

Set between 0 and 30 degrees; patients remain surprisingly functional despite the restriction.

What is the primary goal of scoliosis bracing, and which patients is it intended for?

Scoliosis bracing primarily addresses children with idiopathic scoliosis. The goal is to correct the curve by at least 50%, while recognizing that some regression toward the pre-bracing alignment may occur after bracing ends.

Why must scoliosis bracing occur before skeletal maturity, and how is skeletal maturity assessed?

Bracing must occur before skeletal maturity. Maturity is assessed using the child's age and radiographic evidence of spinal skeletal growth. For girls, the onset of menarche is also evidence of spinal maturity.

What factors are considered when assessing the risk of scoliosis progression?

An earlier onset of scoliosis indicates a higher risk of developing a severe curve. Clinicians also track curve magnitude, secondary rotation, and curve characteristics through surveillance at six-month intervals.

When is orthotic intervention likely insufficient for scoliosis, and what treatment may be indicated?

For children with a curve greater than 50 degrees, orthotic intervention is likely insufficient, and surgery may be indicated.

What are the three primary mechanisms of control used in scoliosis bracing?

- Endpoint control: Controls spinal position through distal spinal points.

- Sagittal-plane corrective forces: Attempt to reduce or minimize spinal curvature.

- Transverse loading: Reducing the curve decreases abnormal spinal loading that could otherwise worsen curve progression.

What are the characteristics and indications of the Milwaukee brace?

The traditional Milwaukee brace uses endpoint control and is designed to be worn 23 hours per day, with removal only for bathing. It has been shown to be the most effective at controlling upper thoracic curves.

What are the limitations of the Milwaukee brace?

Some users experience difficulty tolerating the mandibular endpoint control. The demanding wearing schedule also creates compliance and tolerance issues, so the brace is no longer commonly used.

Why was the Boston thoracolumbosacral orthosis (TLSO) developed?

The Boston TLSO was developed in response to the poor tolerance of the Milwaukee brace. It lacks the terminal neck endpoint and includes open relief areas to improve wearing tolerance.

How is the Boston TLSO fitted, and how does its effectiveness compare with the Milwaukee brace?

The Boston TLSO was initially designed as a prefabricated brace but can also be custom-molded for improved fit. Studies have shown comparable outcomes to the Milwaukee brace, although it may be less effective for upper thoracic curves.

What are the characteristics and indications of the Charleston nighttime brace?

The Charleston brace is designed to be worn only at night. It provides greater curve correction than either the Milwaukee or Boston brace, and it is a viable option for smaller, single curves measuring approximately 25-35 degrees.

Why may the Charleston brace's greater curve correction be more tolerable at night?

The correction is more tolerable at night because the wearer is not in a loaded spinal position.

Do nighttime braces eliminate compliance issues?

No. Compliance remains an issue even with nighttime bracing. Although the Charleston brace avoids barriers such as wearing a brace to school or social events, some users still have difficulty complying with the prescribed schedule.

How does the SpineCor brace differ from rigid scoliosis braces?

The SpineCor brace uses nonrigid, harness-like bands to apply corrective forces rather than a rigid structure. The band configuration depends on the corrective directions indicated by the spinal curvature. The brace is custom-fitted with the assistance of software.

What does the evidence indicate about the effectiveness of the SpineCor brace?

The evidence remains inconclusive. One study found no meaningful difference between SpineCor and another brace option, while other studies showed lower success with SpineCor, with fewer patients successfully preventing curve progression.

What is known about SpineCor brace compliance compared with rigid braces?

The lecture notes that evidence comparing SpineCor compliance with compliance for more rigid braces was not found. Therefore, no conclusion about its relative compliance can be made from the available information.