Week 6: LE Orthosis pt 2

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