Orthotics and Prosthetics Notes

Orthosis & Prosthesis

Orthosis

• Definition: An external device used to modify the structural and functional characteristics of the neuromuscular and skeletal system.

• Components of Upper Portion:

  • Sole

  • Reinforcements

  • Upper vamp - anterior section

  • Quarter - posterior section

  • Space for medial and lateral malleolus

  • Tongue

  • Throat

  • Blucher/Derby - connected to vamp

  • Balmoral/Oxford - separate piece

  • Open to the toe/surgical - longest tongue, reaching the toes

• Components of Sole:

  • Outer - cushions impact

  • Inner - custom made

  • Widest point - where ball of metatarsal heads rest

• Shank:

  • Shank piece

• Toe Box:

  • Protects toes from trauma

  • Consider foot deformities

• Heel:

  • Calcaneus crest - increase in height

  • Heights:

    • Spring: $1/8$ inch ($0.125$ in)

    • Oxford: $6/8$ inch ($1$ in) (MC - most common)

    • Military: $10/8$ inch ($1.25$ in)

    • Cubat: $12/8$ inch ($1.5$ in)

• Counter:

  • Shape of shin and quarter.

• Oxford Boots: Restrict ankle motion

• Closure:

  • Adjustable: Lace, buckle, velcro

  • Non-adjustable: Zipper and close

• Openings: Balmoral and Blucher

• MINC Breast

Lower Extremity Orthosis

• References: NYU book, Sullivan, Braddom

• Types: AFO (Ankle Foot Orthosis), KAFO (Knee Ankle Foot Orthosis), HKAFO (Hip Knee Ankle Foot Orthosis)

• Orthosis vs. Prosthesis:

  • Orthosis: Attachment

  • Prosthesis: Replacement

Ankle Foot Orthosis (AFO)

• Types:

  • Solid Plastic AFO

    • Plastic: Normal sensation

    • Metal: Edema, sensory loss

• Ankle Joint Control:

  • Single axis: Dorsiflexion (DF) and Plantarflexion (PF)

  • Polycentric: Multidirectional

• Ankle Control Mechanisms:

  • Ankle stop: Anterior (DF stop) & Posterior (PF stop)

    • Controls movement

    • Anterior: Calcaneus deformities, paralysis of triceps surae, post foot drop, weak DF muscles

    • Posterior: Equinus deformities

• Talipes: Congenital foot twisted into abnormal position.

  • Tali (ankle), Pes (foot)

  • Talipes cavus: High arc foot

  • Talipes equinus: Plantarflexed foot

  • Talipes calcaneus: Dorsiflexed foot

  • Talipes valgus: Abducted & everted

  • Talipes varus: Adducted & inverted

• Medial T strap: For valgus/eversion

• Lateral T strap: For varus/inversion

Specific AFO Types

• PLS (Posterior Leaf Spring):

  • Weak dorsiflexors

  • No medial malleolus support

• Spiral AFO:

  • Calf band and spiral shoe insert

  • Allows transverse rotation; restricts other movements

• Solid AFO:

  • Spasticity, hemiplegia (stroke, cerebral palsy)

  • AFO with flange controls supination

Knee Ankle Foot Orthosis (KAFO)

• Thigh bands, calf band, shoe insert

• Lateral uprights (two metal bars)

• Stirrup (U shape at the heel)

• Knee joint mechanism & Ankle joint mechanism

  • Single axis & Polycentric

• Locks:

  • Drop ring lock: Simplest; requires fine motor coordination skills

  • Bail lock: Requires hook grip

Special Types of KAFO

• Scott-Craig Orthosis:

  • To stand and walk

  • Most common in Spinal Cord Injury (SCI) patients

Hip Knee Ankle Foot Orthosis (HKAFO)

• Pelvic band/corset (Silesian belt)

• Single axis & Polycentric (includes rotation, internal rotation (IR), external rotation (ER))

Patellofemoral Orthosis

• For Patello-femoral disorders

• Palumbo brace

Control of Knee in Sagittal Plane

• Swedish Knee Cage:

  • Controls/prevents knee hyperextension (genu recurvatum)

  • Promotes flexion

Pediatric Orthosis

• Dennis-Brown Splint: For talipes equinus varus

• A-frame

Developmental Dysplasia of Hip

• Von Rosen

• Ilfeld splint

• Pavlik Harness

• Frejka Pillow

Legg-Calve-Perthes Disease

• Avascular disease of femoral neck

• Trilateral Ortho

• Toronto

• Scottish Rite

Severe Paralytic Disorders

• Caster cart

• Standing frame: Improves balance in standing

• RGR (Reach, Grasp, Release) exercise

• Parapodium: For ambulation; allows pivoting of hip

• Reciprocating Gait Orthosis (RGO): For high level SCI & spina bifida

SCI Levels and Orthoses

• SCI Level T1-T8: KAFO + walker

• SCI Level T9-T11: KAFO + walker + swing to gait pattern

• SCI Level T12-L3: KAFO + Lofstrand/Forearm (FA) crutches + 4-point gait pattern

• SCI Level L4-L5: AFO + FA crutches + 2-point alternating gait pattern

  • Swing to 4-point

Spinal Orthosis

• Classification:

  • Flexible (common)

  • Rigid

• Soft Collar:

  • Soft tissue injury, arthritic changes

  • Limits flexion & extension

• Philadelphia Collar:

  • Limits flexion, extension, lateral flexion

Lumbosacral Orthoses

• Chairback:

  • Controls flexion & extension

  • Thoracic band, pelvic band, posterior uprights

  • Thoracic straps, waist straps (middle), pelvic straps, abdominal pad/support

• Knight:

  • Controls flexion, extension, lateral flexion

  • Thoracic band, pelvic band, posterior uprights, lateral uprights

  • Abdominal pads, straps

• Williams:

  • Controls extension & lateral flexion

  • Thoracic band, pelvic band, lateral uprights, oblique lateral uprights

  • Straps

Thoracolumbar Orthoses

• Taylor:

  • Controls flexion & extension

  • Posterior uprights, pelvic band, axillary straps

  • Interscapular band, abdominal pad/support

• Knight-Taylor:

  • Controls flexion, extension, lateral flexion

  • Posterior uprights, lateral uprights, interscapular band

  • Thoracic band, pelvic band, axillary straps, other straps

• Jewett/Anterior Hyperextension Brace:

  • Controls flexion

  • Sternal pad, suprapubic pad, lateral pad, thoracolumbar pad

Spinal Alignment Orthoses

• Milwaukee Brace:

  • Indication: Apex above T6

  • Chin pad, lateral correctional pad, posterior uprights, anterior uprights, pelvic girdle

• Boston/Yamamoto Brace:

  • Indication: Apex below T8

  • Posterior opening

Prosthesis

• Definition: Replacement of a body part

• Most Common: Lower Extremity (LE) > Upper Extremity (UE), Below Knee Amputation (BKA) > Above Knee Amputation (AKA)

• Levels of Amputation:

  • Chopart: Level of talonavicular & calcaneocuboid joints

  • Lisfranc: Level of tarsometatarsal joints

Below Knee Amputation (BKA) Prosthesis

• Ankle foot assembly

• Vault - connects ankle foot assembly to shank

• Shank - symmetrical metal

• Socket - where the stump goes

• Suspension - strap

• Soft insert - attached to the socket

Above Knee Amputation (AKA) Prosthesis

• Ankle foot assembly

• Shank

• Knee joint

• Socket

Ankle Foot Assembly Types

• Articulated: Movement

  • Single axis

  • Multi axis

• Non-articulated: No movement

  • Most Common: Solid Ankle Cushion Heel (SACH)

    • Keel: Wooden in the middle

    • Simulates plantar flexion

    • Belt below keel: Line that extends along the foot to prevent puncture of the keel in foam

    • Foam: Covering of the foot

    • Stationary Attachment Exo (SAFE): More flexible keel, can perform on uneven surfaces

    • Stored Energy (STEN): 3 keels, high performance (running, jumping, etc.)

    • Flex Walk: Lightweight, increases stability

    • Carbon Copy 2: (Not included in practicals); 2 keels, shorter keel accepts more load, longer keel for base of support (BOS) of patient

    • Flex Foot: May have extension up to shank, more stable, more energy return

Shank

• Endoskeleton: Inside; metal

• Exoskeleton: Crustacean - more cosmetic

Socket

• Patellar Tendon Bearing (PTB):

  • Common in BKA

  • $100\%$ weight-bearing

  • Patient must know how to bear weight on patellar tendon

• Supracondylar Patellar Tendon Supracondylar Suprapatellar: Higher lateral wall stability for mediolateral support for short BKA

Suspension

• Supracondylar cuff

• Most common thigh corset for big thighs

AKA Sockets

• Quadrilateral: Shape like quad

• Ischial Containment: Most Common, more rounded shape

Pressure Relief

(Included in practicals)

• BKA Pressure Sensitive Areas:

  • Peroneal nerve

  • Anterior tibia

  • Fibular head & neck

  • Anterior tibial crest

• BKA Pressure Tolerant Areas:

  • Patellar tendon

  • Tibia & fibular shaft

  • Medial tibial plateau

  • Distal end of stump

• AKA Sensitive Areas:

  • Pubic symphysis

  • Distolateral head of femur

  • Perineal area

• AKA Tolerant Areas:

  • Gluteals

  • Lateral side of residual limb/stump

  • Distal end of stump

  • Ischial tuberosity

  • Semimembranosus Insertion Point