Week 6: LE Orthosis pt 2

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Straight Set Knee Joint

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1

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

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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

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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

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GRF to initial contact

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

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GRF to post. offset

  • GRF in anterior, improved and inc. stability

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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

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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

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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

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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

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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

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11

Genu Valgum/Varu, Correction Shells/Straps

  • buckles around one right to pull the knee

  • promotes frontal plane control

  • Medial Shell, Lat. Shell

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Thigh and Calf Components

  1. Thigh Band

  2. Knee Cap

  3. Knee Joint

  4. Calf Band

  5. Upright

  6. Ankle Joint

  7. Stirrup

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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

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Design Variations

  1. Single Upright Orthosis

  2. Scott Craig Orthosis

  3. Stance Control Orthosis

  4. Supracondylar KAFO

  5. Oregon Orthotic System

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Single Upright Orthosis

  • one upright (lateral), no medial upright

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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

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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

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18

Stance Control Orthosis

  • control knee during stance phase → inc. stability

  • allow knee flxn during swing phase

  • Requires proper gait training to use device safely

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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

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Oregon Orthotic System

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

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21

HKAFO

  • KAFO + hip jt + pelvic band

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22

Hip Joints and Locks

  • single axis (saggittal)

  • double axis (sagittal + frontal plane)

  • Stops used:

    • Drop locks

    • Pawl lock

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23

Pawl Lock

  • 2 position lock

    • during full extn and

    • during 90 deg flxn

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

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24

Pelvic Bands

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

  • attached to lateral uprights

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25

Unilateral Pelvic Bands

  • flexible belt on outerside

  • involved side encompassing pelvis

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Bilateral Pelvic Bands

  • attached to lateral uprights

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27

Silesian Belts

  • only made of cloth

  • does not control motion in sagittal plane

  • gives during Abd/Add and Rotational Forces

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THKAFO

  • lumbosacral orthosis (LSO) + KAFO

  • very difficult to don

  • poor pt compliance

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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)

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Knee Orthoses

  • for Patellofemoral Pain Syndrome (PFPS)

  • for Angular Motion Control in Frontal and Sagittal Plane

  • for Axial Rotation Control

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Patellofemoral Pain Syndrome (PFPS)

  • chondromalacia patella (runner’s knee)

    • cartillage in patella softens

  • Cho-Pat Brace

  • Palumbo Brace

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Cho-Pat Brace

  • foam padded infrapatellar strap which encircles the knee

  • worn during activity (esp athletes) to support knee

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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

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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)

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Swedish Knee Cage

  • for (+) genu recurvatum

  • 2 ant, 1 post strap

  • (+) full flxn, (-) hyperextn

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

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3- way stabilizer

  • more cosmetic d/t circumferential/pivotal attachments

  • 2 uprights

  • provides limited mediolateral stability

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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

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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

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Lenox Hill Derotation Brace

  • for pt (+) ACL

  • improve stabilty and counter rotational forces

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Lerman Multi-ligamentous Knee Control Orthosis

  • condylar pad

  • controls mediolateral stability of patella

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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)

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Specialized Orthoses

  • For leg length Discrepancy

  • Weight Bearing Orthosis

  • Fracture Orthosis

  • Pediatric Orthosis

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True Leg Length Discrepancy

  • from ASIS to medial epicondyle

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Apparent Leg Length Discrepancy

  • measures from umbilicus to medial epicondyle

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45

0-1 cm

  • no treatment

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1-2 cm

  • conservative (exercises, stretching, etc)

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2-5 cm

  • heel lifts, shoe modifications

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5-20 cm

surgical (bone grafting)

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49

20cm

prosthetic

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50

Weight Bearing Orthosis

reduced by transmission

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51

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

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Ischial/Quadrilateral Weight Bearing Orthosis

  • Offload: femur, knee, ankle, foot

  • WB: ischial tuberosity/sitting bone

  • pt (+) ischial tuberosity/sitting bone

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53

Ischial Ring

  • simpler to fabricate

  • minimal weight relief

  • I: minimal weight relief

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54

Quadrilateral Ring

  • stability and more weight relief

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55

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

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56

Fracture Orthosis

  • Promote movement in adjacent joints

  • promote weight-bewaring

  • promote callus formation

  • prevent joint stiffness and reducing complication

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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

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Femoral Fracture Orthosis

  • mid/distal 1/3 femur

  • (+) callus formation and (-) pain

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59

Pediatric Orthosis

  • Angular and Rational Deformities

  • Congenital Hip Dislocation and Dysplasia

  • Legg-Calve Perthes Disease

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Angular and Rotational Deformities

  • Dennis Browne Splint

  • A Frame

  • Torsion Strap Orthosis

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Dennis Browne Splint

  • c clubbed foot hyperpronated, abnormal tibial torsion

  • Components:

    • Spreader bar: skateboard, corrects abd and add component

    • Foot Plates: underfoot, rotation component

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A Frame

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

  • calf band and thigh band and pressure pads

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63

Torsion Strap Orthosis

  • Hip rotation contral straps

  • pt (+) spastic hemiplegia

  • abnormal in-toeing and out-toeing

  • light-weight, easy to don, cosmetic

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Congenital Hip Dislocation and Dysplasia

  • LE in FAB

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

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Von Rosen Splint

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

  • horizontal straps in trunk: secure splint

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Ilfeld Splint

  • thigh bands and connected with crossbar and spreader bar

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67

Pavlik Harness

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

  • no rigit component, greatest mobility

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68

Bootees

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

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69

Frejka Pillow

  • milder and stable dysplasia

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70

Legg-Calve-Perthes-Disease

  • coxa plana/juvenile avascular necrosis of femoral head

  • deformity: FADER

  • Facilitate FABIR

    Orthosis

    • Trilateral Orthosis

    • Toronto Orthosis

    • Scotish Rite Orthosis

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71

Chandler’s Disease

  • adult LCPD

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Trilateral Orthosis

  • unilateral c single medial upright and has shoe attachment

  • holds extremity in ABIR

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Toronto Orthosis

  • X in middle

  • Superior end tube joins bilateral band

  • Inferior End hold horizontal spreader bar

  • Hold pt to ABIR

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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

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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

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Detachable Hip Joint

I: high level SCI lesions that require easier transition

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Caster Cart

  • Initial mobility aid

  • for children with developmental delay and ambulation, spina bifida

  • Requirement: UE strength, Trunk Balance

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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

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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

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80

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

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Swivel Walker

  • both children and adults

  • 2 distal plates that retracts lightly

  • swiveling gait and moving plate below

  • easier to use

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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

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Standard Cane

  • single point cane/straight cane

  • inexpensive but not adjustable

  • commonly made from wood

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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

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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

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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

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Hemi cane

  • 4 point contact

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

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Rolling Cane

  • allows uninterrupted forward progression

  • pushing while providing enough stability

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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

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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

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Prescription of Walker

12 in. in front of pt

  • Height: 20-30 deg flexion

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Types of Walker

  • Adds Weight

  • Adds Wheels

  • Reciprocal Walker

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Adds weight

  • for pt c enough UE strength, coordination problem

  • improve proprioceptive feedback

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Adds Wheels

  • no UE coordination

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

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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

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Axillary Crutches Compnents

  • Axillary Bar

  • Double Upright

  • Handpiece

  • Single Leg

  • Rubber section/Rubber

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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)

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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

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Computation for Axillary Crutches

  • Supine

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

  • Estimate:

    • pt height minus 16 inc

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Forearm Crutches

  • Loftstrand

  • Wooden Forearm

  • Platform Forearm

  • Triceps Weakness Orthosis

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