Week 6: LE Orthosis pt 2

Straight Set Knee Joint

Straight Set Knee Joint

• (+) free flexion, (-) hyperextension

• for pt c sufficient knee muscle strength, for pt c genu recurvatum which provides mediolateral knee stability

• most common, used c drop lock

Polycentric Knee Joint

• double axis system to stimulate flxn/extn movements of femur and tibia

• not biaxial, used for sagittal plane only

• tibia rotates on distal axis, femur on proximal axis

• less commonly prescribed d/t its bulkiness, common as sports knee orthoses

Posterior Knee Joint

• and hinge at post. of knee joint

• curved posteriorly, GRF → ant., →extension moment

• for pt (+) weakness of knee extnsors c (+) little hip extensor strength

• NOT ENOUGH OFFSET OF KNEE: add ankle component set to 10-15 deg PF to increase stability

  • If not enough, add drop ring lock

GRF to initial contact

• GRF is posterior to the knee joint c ext moment → dec stability

GRF to post. offset

• GRF in anterior, improved and inc. stability

Ratchet Lock

• most commonly prescribed

• used for (+) knee flxn contracture

• locking until fully extending

• catching mechanism: 12 deg increments

• sliding mechanism: go back to flexion

Drop/ Ring/Drop Ring Lock

• most common before ratchet

• simples, sturdy, not bulky

• attached to both uprights 4 drop locks in total

• full extension: ring drops towards knee joint, no locking mechanism

• c/i to pt (+) knee flxn contracture

Bail Lock

• pawl, swiss, french, schweitzer lock

• easiest method of simultaneous locking and unlocking of both uprights

• locking mechanism: spring loaded to assist full extension

• c/i: pt (+) knee flexion contracture

• pt prone to bullying

Dial Lock

• turnbuckle, serrated, or fan knee lock

• more precise for managing knee flexion contracture

• 6 deg increments

• Proximal Component: drop ring lock

• Distal Component: Dial Lock

• Not commonly used, no other mechanisms aside from locking

Knee Cap

• also called anterior band

• ant. to knee, secured to the uprights with straps

• applies posterior force to counteract knee flexion to improve stability

• reduces discomfort between the knee and the orthotic cuff during stance phase

• similar to padding system

Genu Valgum/Varu, Correction Shells/Straps

• buckles around one right to pull the knee

• promotes frontal plane control

• Medial Shell, Lat. Shell

Thigh and Calf Components

1. Thigh Band

2. Knee Cap

3. Knee Joint

4. Calf Band

5. Upright

6. Ankle Joint

7. Stirrup

Thigh Band

• should be wide enough to distribute pressure

• uses partial plastic thigh shell: larger contact are for more distal pressure)

• Low Thigh Band: pt (+) genu recurvatum

Design Variations

1. Single Upright Orthosis

2. Scott Craig Orthosis

3. Stance Control Orthosis

4. Supracondylar KAFO

5. Oregon Orthotic System

Single Upright Orthosis

• one upright (lateral), no medial upright

Scott Craig Orthosis

• (+) SCI L1 level or higher

• easiest KAFO to don and doff

• provide orthotic stability for knee, ankle and foot

• hip: stability is dependent on passive ligament stability of Y ligament of bigelow

Components of Scott Craig

• Shoe reinforced c transverse and longitudinal plates

  • T-shape and cushion heel

  • BiCAAL

    • Anterior stop: 5 deg DF

    • Posterior Stop 90 deg to prevent toe drag

• Rigid Anterior Band

• Single tight band posteriorly

• Offset knee joint

Stance Control Orthosis

• control knee during stance phase → inc. stability

• allow knee flxn during swing phase

• Requires proper gait training to use device safely

Supracondylar KAFO

• durable

• pt (+) knee extensor weakness

• cannot be used bilat.

• resists recurvatum and provides mediolateral stabilization

  • Distal Portion: limits subtalar motion and immobilizes ankle into slight PF

  • Proximal Portion: protruded during sitting

Oregon Orthotic System

• AFO version + thigh band + 2 uprights + corrugations + BICAAL

HKAFO

• KAFO + hip jt + pelvic band

Hip Joints and Locks

• single axis (saggittal)

• double axis (sagittal + frontal plane)

• Stops used:

  • Drop locks

  • Pawl lock

Pawl Lock

• 2 position lock

  • during full extn and

  • during 90 deg flxn

• for pt c difficulty maintaining sitting position d/t spasticity

Pelvic Bands

• upholstered metal band which lodge between greater trochanter and iliac crest

• attached to lateral uprights

Unilateral Pelvic Bands

• flexible belt on outerside

• involved side encompassing pelvis

Bilateral Pelvic Bands

• attached to lateral uprights

Silesian Belts

• only made of cloth

• does not control motion in sagittal plane

• gives during Abd/Add and Rotational Forces

THKAFO

• lumbosacral orthosis (LSO) + KAFO

• very difficult to don

• poor pt compliance

Knee Orthosis & Hip Orthosis

• Thigh & Calf Bands + sidebars + flxn/extn joint + mediolateral pressure pad

• protects knee from mediolateral forces

• has flexion/extn control through hyperextension stop (drop lock)

Knee Orthoses

• for Patellofemoral Pain Syndrome (PFPS)

• for Angular Motion Control in Frontal and Sagittal Plane

• for Axial Rotation Control

Patellofemoral Pain Syndrome (PFPS)

• chondromalacia patella (runner’s knee)

  • cartillage in patella softens

• Cho-Pat Brace

• Palumbo Brace

Cho-Pat Brace

• foam padded infrapatellar strap which encircles the knee

• worn during activity (esp athletes) to support knee

Palumbo Brace

• elastic sleeve c patella cutout c 2 circumferential straps that provide dynamic tension to the crescent-shaped patellar pad

• elastic counterforce posteriorly to maintain the crescent pad position and prevent axial rotation of device

For angular Motion Control in Frontal and Sagittal Plane

• Swedish Knee Cage

• Miami Cage

• 3-way stabilizer

• Canadian Arthritis Rheumatism Society-University of British Columbia (CARS-UBC)

Swedish Knee Cage

• for (+) genu recurvatum

• 2 ant, 1 post strap

• (+) full flxn, (-) hyperextn

• does not give mediolateral stability d/t (-) hinge

3- way stabilizer

• more cosmetic d/t circumferential/pivotal attachments

• 2 uprights

• provides limited mediolateral stability

Canadian Arthritis Rheumatism Society - University of British Columbia (CARS-UBC) Orthosis

• for genu varum and valgum

• 2 plastic cuffs at the thigh and the leg is connected by a telescopic rod to control valgum and varum deformity

• rod: connected to a 3rd point of force

• no control of axial rotation

• more on frontal plane

For Axial Rotation Control

• both have elastic straps that exert forces for rotation stability only and is used in prevention and Mx of knee injuries

  • Lenox Hill Derotation Brace

  • Lerman Multi-ligamentous Knee Control Orthosis

  • Hip Orthosis

Lenox Hill Derotation Brace

• for pt (+) ACL

• improve stabilty and counter rotational forces

Lerman Multi-ligamentous Knee Control Orthosis

• condylar pad

• controls mediolateral stability of patella

Hip Orthosis

I: Adductor Spasticity, s/p hip replacement or THR

Components:

• 2 position hip lock

• adjustable adduction stop

• thigh calf extension up to medial condyle (controls adduction and IR)

Specialized Orthoses

• For leg length Discrepancy

• Weight Bearing Orthosis

• Fracture Orthosis

• Pediatric Orthosis

True Leg Length Discrepancy

• from ASIS to medial epicondyle

Apparent Leg Length Discrepancy

• measures from umbilicus to medial epicondyle

0-1 cm

• no treatment

1-2 cm

• conservative (exercises, stretching, etc)

2-5 cm

• heel lifts, shoe modifications

5-20 cm

surgical (bone grafting)

20cm

prosthetic

Weight Bearing Orthosis

reduced by transmission

PTB Orthosis

• Patellar Tendon Bearing

• Reduces: mid/distal tibia, ankle and foot

• Weight Bearing: On patellar tendon and tibial flares

• cushion heel and rocker bar: push off d/t limited ankle motion

Ischial/Quadrilateral Weight Bearing Orthosis

• Offload: femur, knee, ankle, foot

• WB: ischial tuberosity/sitting bone

• pt (+) ischial tuberosity/sitting bone

Ischial Ring

• simpler to fabricate

• minimal weight relief

• I: minimal weight relief

Quadrilateral Ring

• stability and more weight relief

Patten Bottom

• Offload: Whole LE

• total elimination of WB in limb

• no ankle joint, uprights terminate at distal shoe

• consists of floor pad and shooe lift

Fracture Orthosis

• Promote movement in adjacent joints

• promote weight-bewaring

• promote callus formation

• prevent joint stiffness and reducing complication

Tibial Fracture Orthosis

• 4 wks post fracture

• thermoplastic material

• has plastic cable ankle joint: allows motion in ankle

• plastic thigh section, fracture in tibial plateau or tibial condyles for stability

Femoral Fracture Orthosis

• mid/distal 1/3 femur

• (+) callus formation and (-) pain

Pediatric Orthosis

• Angular and Rational Deformities

• Congenital Hip Dislocation and Dysplasia

• Legg-Calve Perthes Disease

Angular and Rotational Deformities

• Dennis Browne Splint

• A Frame

• Torsion Strap Orthosis

Dennis Browne Splint

• c clubbed foot hyperpronated, abnormal tibial torsion

• Components:

  • Spreader bar: skateboard, corrects abd and add component

  • Foot Plates: underfoot, rotation component

A Frame

• has spreader bar, c A metal frame (triangle)

• calf band and thigh band and pressure pads

Torsion Strap Orthosis

• Hip rotation contral straps

• pt (+) spastic hemiplegia

• abnormal in-toeing and out-toeing

• light-weight, easy to don, cosmetic

Congenital Hip Dislocation and Dysplasia

• LE in FAB

• inc contact of femoral head and acetabulum and lesser chance of hip dislocation

Von Rosen Splint

• vertical straps from shoulder to thigh: hold in flxn and abd

• horizontal straps in trunk: secure splint

Ilfeld Splint

• thigh bands and connected with crossbar and spreader bar

Pavlik Harness

• has shoulder harness, chest strap, ant and post strap and connected to bootees

• no rigit component, greatest mobility

Bootees

• in the foot of baby to have leverage to hold in flxn and abd

Frejka Pillow

• milder and stable dysplasia

Legg-Calve-Perthes-Disease

• coxa plana/juvenile avascular necrosis of femoral head

• deformity: FADER

• Facilitate FABIR

  Orthosis

  • Trilateral Orthosis

  • Toronto Orthosis

  • Scotish Rite Orthosis

Chandler’s Disease

• adult LCPD

Trilateral Orthosis

• unilateral c single medial upright and has shoe attachment

• holds extremity in ABIR

Toronto Orthosis

• X in middle

• Superior end tube joins bilateral band

• Inferior End hold horizontal spreader bar

• Hold pt to ABIR

Scotish Rite Orthosis

• Lightest, least restrictive

• holds limb into FAB

• Components:

  • Pelvic Band or Cuff

  • 2 Thigh cuffs

  • 2 Thigh Joints

  • Connected by telescoping rod

Severe Paralytic Disorder Orthosis

• Pts c SCI, Spina Bifida, paralyzed LE, developmental delay, cerebral palsy

• Detachable hip Joint

• Caster Cart

• Standing Frame

• Reciprocating Gait Orthosis

Detachable Hip Joint

I: high level SCI lesions that require easier transition

Caster Cart

• Initial mobility aid

• for children with developmental delay and ambulation, spina bifida

• Requirement: UE strength, Trunk Balance

Standing Frame

• 8-15 mos after caster cart

• Can be used through gait in parallel bars

• Components:

  • Broad Base

  • Posterior non-articulated upright

  • Anterior Leg band

  • Posterior thoracolumbar band

Reciprocating Gait Frame

• Hip guided orthosis/bilateral HKAFO

• 3-6 yrs

• contralateral hip extension with ipsilateral hip flexion to mimic the normal gait pattern

• Requirement:

  • Standing frame use

  • safely stand

  • active hip flexion

Parapodium

• Swivel Orthosis

• 2 1/2 - 5 y/o

• Allows crutchless gait

• Swivel or pivot hips to propel one side forwardly, allow sitting d/t knee and hip joints

• Requirement: adequate standing frame use

Swivel Walker

• both children and adults

• 2 distal plates that retracts lightly

• swiveling gait and moving plate below

• easier to use

Cane

• unaffected side: hip joint prob

  • advance/simultaneous with affected side

  • decreases work of hip abductors

  • carries pelvis of affected side

• affected side: knee joint, helps in WB

• Tip: 6 in lat to toes,

• Handle: upper border of greater trochanter

• Elbow Flexion 20-30 deg

  • allow arm to shorten and lengthen during different phases of gait

  • provides shock absorption mechanism

Standard Cane

• single point cane/straight cane

• inexpensive but not adjustable

• commonly made from wood

Standard Adjustable Aluminum Cane

• telescoping design

• more lightweight than standard

• Disadvantage

  • same c standard cane

  • point of support is far or outside of BOS → unstable

  • more expensive

Adjustable Aluminum offset cane

• handle is off set anteriorly

  • fixes drawbacks of the first two canes

  • same level to hand → improved stability

• Disadvantage: more expensive

Quad Cane

• quadrupe cane

• increases area of support

  • narrow and wide base forms depending on the degrees of support needed

  • outside legs: directed outside the body

  • closest leg: shorter to allow foot clearance

Hemi cane

• 4 point contact

• outer legs are angled to maintain floor contact and helps maintain stability

Rolling Cane

• allows uninterrupted forward progression

• pushing while providing enough stability

Laser Cane

• has bright red laser line across floor

• assist freezing episodes

• Parkinson’s dse d/t akenisia.

• provides prompt to pt during freezing episodes

Walkers

• provides max support for pt

• pt pushes or lifts the walker in front of themselves while walking

• slow gait

• for pt (+):

  • Hemiplegia

  • Balance Problem

  • Ataxia

  • Severe sensory deficits

  • Fear of Falling

• Requirements:

  • bilateral grasp and arm strength

• Disadvantage:

  • bulky in appearance

  • difficult to maneuver

  • interferes c development of reciprocal gait

Prescription of Walker

12 in. in front of pt

• Height: 20-30 deg flexion

Types of Walker

• Adds Weight

• Adds Wheels

• Reciprocal Walker

Adds weight

• for pt c enough UE strength, coordination problem

• improve proprioceptive feedback

Adds Wheels

• no UE coordination

• difficulty in using typical walker, just pushes while providing bilateral support

Reciprocal Walker

• pt incapable of lifting walker c both hands

• front portion has joints, allows pt to swivel one side of walker → allows unilateral progression

Axillary Crutches Compnents

• Axillary Bar

• Double Upright

• Handpiece

• Single Leg

• Rubber section/Rubber

Axillary Crutches

• standard crutches

• single leg has multiple holes and telescoping design for height adjustment

• body weight on hands, not on axillary bar to prevent compressive radial neuropathy (crutch palsy)

Prescription for Axillary Crutches

• Tip 2 inc lat, 6 inch ant to toes

• Axillary Bar: 2 in below axilla

• Handpiece: allow 20-30 deg elbow flexion

• pt should be able to raise the body to 1-2 inch by complete elbow extn

Computation for Axillary Crutches

• Supine

  • Length: form ant. axillary point to 6-8 in lateral border of heel

• Estimate:

  • pt height minus 16 inc

Forearm Crutches

• Loftstrand

• Wooden Forearm

• Platform Forearm

• Triceps Weakness Orthosis