Orthotic Overview Study #3

The stance phase of gait makes up what percent of the gait cycle during ordinary walking speeds: A) 40% B) 60% C) 50% D) 20%

60%

At heel strike the knee joint is at ____while the ankle joint is at _____: A) At neutral/full extension, 90 degrees/neutral B) 10 deg flexed, 5 deg plantarflexion C) Neutral, 10 degrees dorsiflexion

A - At heel strike the knee is at neutral or full extension while the ankle is at 90 deg/neutral.

The axillary nerve innervates teres minor. What other muscle does it innervate: A) Deltoid B) Serratus anterior C) Levator scapulae D) Pectoralis minor

A - Axillary nerve also innervates the deltoid. At times there is injury to this nerve with shoulder dislocation.

A patient with C6 quadriplegia is able to use a tenodesis grip. What is the action that occurs: A) Wrist extension which causes MP flexion B) Wrist flexion and MP flexion C) Wrist extension D) Elbow flexion and wrist flexion

A - C6 quadriplegic patients functionally use tenodesis grasp. This is caused by wrist extension which allows passive MP flexion.

You are seeing a patient with diagnosis of peripheral vascular disease. What is the common artery that you can palpate to assess blood flow: A) Dorsalis pedis B) Popliteal artery C) Femoral artery D) Radial artery

A - Clinicians at times will want to assess blood flow in a patients foot. One way is to palpate the dorsalis pedis pulse along with capillary refill.

The clawhand appearance of the hand is due to damage to what nerve: A) Ulnar nerve B) Median nerve C) Radial nerve D) Musculocutaneous nerve

A - Damage to the ulnar nerve commonly occurs where it passes posterior to the medial epicondyle on the humerus. The patient is likely to have difficulty making a fist due to paralysis of the intrinsic muscles of the hand. Clawhand comes from inability to flex the 4th and 5th MCP joint.

A patient sustains a Hangman fracture. This fracture can cause quadriplegia. What vertebrae and location of the fracture is damaged: A) Atlas, lamina (pars interarticularis) C2 B) Axis, lamina (pars interarticularis) C1 C) C3, transverse process D) Axis, spinous process C1

A - Hangman's fracture occurs from fracture through the lamina of the axis. Another injury to the axis is displacement of the dens which may also cause quadriplegia.

A patient has chief complaint of pain on the medial side of her ankle just below the medial malleoli. On clinical examination the patient has slight weakness with inversion, pes planus, pain with heel raises and tenderness and swelling under the medial malleoli. The most likely cause of the sympatientoms would be: A) Posterior tibial tendonitis B) Tarsal tunnel syndrome C) Accessory navicular D) Compartmental syndrome

A - Posterior tibial tendonitis can present with inversion weakness, inability to perform heel raise, and tenderness under the medial malleoli. Compartment syndrome can be an emergency, often in the calf, with tissues swelling. Tarsal tunnel syndrome is due to compression of the posterior tibial nerve through the tarsal tunnel on the medial side of the ankle. Often these patients report neuralgia, tingling into medial side of the foot.

Anterior displacement of the vertebral body on the lower vertebrae is called what: A) Spondylolisthesis B) Spondylosis C) Spondylitis D) Spinal stenosis

A - Spondylolisthesis is described by the percentage of the anterior displacement of the vertebral body described by 4 grades (Grade 1 0-25%, Grade 2 25-50%, Grade 3 50-75%, Grade 4 75-100%) Spinal stenosis is the narrowing of the spinal column. Spondylosis is a term for osteoarthritis of the spinal column or neural foramen. Spondylitis is inflammation of the vertebra.

T/F, A patient utilizing an articulated AFO with a full foot plate complains that it is hard to roll over their foot smoothly throughout stance. Recommending rocker sole shoes and or cutting the foot plate to sulcus length would be appropriate (assuming they have good knee stability in the sagittal plane):

A - Sulcus length foot plates and rocker sole shoes can both contribute to a relatively smooth roll over in stance phase

The deltoid muscle acts to abduct the shoulder with what other muscle: A) Supraspinatus B) Infraspinatus C) Subscapularis D) Trapezius

A - Supraspinatus part of the rotator cuff assists with abduction of the glenohumeral joint.

The claw hand appearance is characterized by an injury to what nerve: A) Ulnar nerve B) Median nerve C) Radial nerve D) Musculocutaneous nerve

A - Ulnar nerve injury will result in 4th and 5th MCP joints extended and the IP joints of the same fingers are flexed.

A patient has a fixed forefoot varum. All of the following are considered compensatory strategies for a fixed forefoot varus malalignment EXCEPT: A) Subtalor supination B) Plantar flexed first ray C) Subtalor pronation D) Tibial internal rotation

A - With a fixed forefoot varus alignment subtalor pronation, plantar flexed first ray, tibial and femoral internal rotation. Subtalor supination would be common with a forefoot valgus deformity.

The nominate bone of the pelvic girdle is known as: A) Sacrum B) Ilium C) Ischium D) Symphysis pubis

A -The pelvic girdle is made up of the innominate bones of the iliums that articulate with the sacrum known as the nominate bone.

A patient is seen at the local hospital Ortho/Neuro floor. The patient presents with an unstable odontoid fracture. Which orthosis would you recommend:

A HALO CTLSO is indicated for unstable C1 and C2 fractures. This orthosis spans a long distance to maximize end-point control.

A Knight Taylor TLSO is classified as _______________ control TLSO; where a Taylor TLSO is classified as ______________ control TLSO:

A Knight Taylor is an A/P M/L control TLSO, while a Taylor is an A/P control TLSO.

A scoliosis patient is seen in clinic. Upon radiographic reading you note that the patient has a risser sign of 5. How would you describe this risser sign:

A risser sign of 5 is described as complete osseous capping of the iliac crest apophyseal plate and signals skeletal maturity.

A patient has failed conservative treatment for plantar fasciitis including foot orthotics, physical therapy, shoe wear modifications. Choose all that are common surgical interventions: A) Gastroc lengthening procedure B) Plantar fascia release C) Ankle fusion D) Triple arthrodesis

A) Gastroc lengething and B) Plantar flascia release are two common surgical procedures once a patient has failed conservative treatment. Ankle fusion and triple arthrodesis surgeries are not performed for plantar fasciitis. Usually treated for arthritis with fusion of the calcanealcuboid, talonavicular, and talocalcaneal joints of the foot.

Pick the following choice that best describes Legg-Calve-Perthes disease (osteochondrosis): A) Males>females, age onset 13 years, AROM restricted in abduction, flexion, and internal rotation, vague pain at hip, knee, and thigh B) Etiologies resulting in lack of blood supply to the femoral head, AROM is decreased in hip flexion, internal rotation, and abduction, pain at groin, thigh, tenderness at hip C) Males>females, average age onset 6 years old, psoatic limp due to psoas major weakness, lower extremity moves into external rotation, flexion and adduction, MRI will show collapse of subchondral bone at femoral neck D) Characterized by restriction in shoulder motion in external rotation, abduction and flexion, inflammation and fibrosis as the shoulder

A) Males>females, age onset 13 years, AROM restricted in abduction, flexion, and internal rotation, vague pain at hip, knee, and thigh describes slipped capital femoral epiphysis

You have provided a patient with an articulated AFO and PF stop. When the patient ambulates you notice that they have pronounced knee flexion during loading response. Choose the options that can cause this: A) Firm extrinsic heel wedge B) PF stop is too dorsiflexed C) Shoe heel is too soft D) PF stop is too plantarflexed

A,B - Both of these can cause ground reaction forces to translate posterior to the knee joint rapidly causing abrupt knee flexion during loading response.

What are some of the biomechanical principals behind a LSO corset? Choose all that apply: A) Kinesthetic reminder B) Increased intra-abdominal pressure C) Multiple three point pressure systems D) Decreased lumbar lordosis

A,B,C - An LSO corset provides a kinesthetic reminder to use proper posture and to discourage certain motions. Increased intra-abdominal pressure solidifies soft tissue hydrostatically whereby providing support to the lumbar spine. Three point pressure systems work to hold proper alignment and resist or stop certain motions.

What additions can you make to an AFO to decrease excessive pronation within the AFO: A) Extrinsic medial wedge B) Medial Sabolich tab or trimline C) Sustentaculum tali "ST" pad D) Extrinsic lateral wedge

A,B,C - These three additions can be utilized for decreasing pronation forces.

Select all that are found in Scarpa's triangle (femoral triangle): A) Femoral nerve B) Femoral artery C) Sartorius muscle D) Inguinal lymph nodes

A,B,C,D - All are found within Scarpa's triangle> it is also important to remember its boundaries. A mnemonic to remember is SAIL: Sartorius, Adductor longus, Inguinal Ligament.

Choose all the pathologies that indicate the need for a first ray relief and lateral wedge in a functional foot orthotic: A) Cavo varus foot B) Peroneal tendon dysfunction C) Chronic lateral ankle sprains D) Jones fracture

A,B,C,D - All of the above are pathologies that can be treated with a decrease in MLA support and an increase in 1st MTP relief with a lateral extrinsic wedge. A - provides neutral alignment to decrease likelihood of multiple pathologies, B - decreases work load of peroneal tendons, C - provides canting to decrease lateral ankle sprains, D - decreases pressure under the 5th metatarsal. NOTE: fabrication varies but in general should be made of material of low durometer. Individuals prone to these pathologies in most instances have a cavo varus foot (rigid foot shape). Softer materials used in fabrication will promote a more compliant foot orthotic which is indicated to achieve our goals.

When designing a thermoplastic KAFO for a patient with severe genu recurvatum, what can you incorporate that will help control the knee hyper extension: A) Extending the dist/post thigh trimline more distally B) Decreasing the depth of the thigh section C) Extending the prox/post calf trimline proximally D) Decreasing the depth of the calf section

A,B,C,D - All of these design modifications will aid in decreasing genu recurvatum

A patellar tendon bearing AFO is indicated for which pathologies: A) Charcot joint B) Avascular necrosis of the talus C) Osteoarthritis of the ankle joint D) Calcaneal fracture

A,B,C,D - All of these pathologies could potentially utilize a PTB AFO to un-weight the affected area during weight bearing.

What would you recommend for additions to an articulated AFO for drop foot and posterior lateral hyperextension thrust of the knee (mild tone is present): A) Elevation of the 2nd-5th MTP joints and digits. B) 1/4" heel/lateral wedge. C) PF stop. D) Metatarsal pad.

A,B,C,D - the PF stop will decrease drop foot in swing, the 1/4" heel/lateral wedge will negate the posterior lateral knee extension thrust, and the metatarsal pad in combination with elevation of the 2nd-5th MTP's and digits have been shown to decrease tone on a relative scale

A child is seen in clinic. The child is playing on the floor and proceeds to use his hands to stand up by pushing off of his lower extremities until upright. What is the name of this maneuver and what diagnosis does this boy most likely have: A) Duchennes muscular dystrophy B) Tinel sign C) Gowers sign D) Amyotrophic lateral sclerosis

A,C - Duchennes muscular dystrophy is most common in young males and is characterized by the gowers sign "walking of hands up lower extremities while standing" which is compensating for proximal lower extremity weakness.

51) When a HALO application is finished all pins for an adult should be torqued to____________ and between 24-48hours the pins should be______________: A) 6-8 inch pounds B) 6-8 newton meters C) Re-torqued D) Removed, disinfected, applied, and re-torqued

A,C - When applying a HALO for an adult all pins should be torqued 6-8 inch pounds, and in the following 24-48hours should be re torqued to 6-8 inch pounds as the HALO may settle and lose torque.

Choose all that describe the design of a GRAFO: A) Anterior/Distal and Posterior/Proximal openings B) Anterior/Distal and Posterior/Proximal areas of AFO contact C) Posterior/Distal and Anterior/proximal openings D) Posterior/Distal and Anterior/proximal areas of AFO contact

A,D - Trimlines for a GRAFO include Anterior/Distal and Posterior/Proximal openings as well as Posterior/Distal and Anterior/proximal areas of AFO contact. Note: it is important to make sure the patient can fit their foot and lower leg through the opening which tends to be narrow, but it is important to trim carefully so as not to lose the supportive structure of the GRAFO.

The "unhappy triad" includes injury to what structures:

ACL, MCL, medial meniscus Forces that cause genu valgum, flexion, and external rotation applied at the knee when the foot is planted.

You are seeing a patient with a one year history of amyotrophic lateral sclerosis. She is ambulating with bilateral canes, shows limited endurance and foot drop. Based on the diagnosis what device would you recommend for trial:

ALS is a progressive degenerative disease where due to the progressive nature you feel trial of ankle foot orthosis would be appropriate due to her fatigue and foot drop The goals for mobility are to maximize current function and provide access to devices that allow for independence including orthosis

A patient is seen in clinic. The patient has bilateral pars fractures at L5 and is currently utilizing a custom polymer overlapping style LSO with decreased lumbar lordosis. The physician is not satisfied with the orthosis results and wants to know what you can do to further immobilize the fracture site?

Add a Hip Spica By adding a hip spica to the LSO you adjust how much hip flexion and extension is allowed which can further immobilize the patient and the fracture site.

Choose all answers that are clinical "visible by the eye" signs of scoliosis: A) Arm gap, shoulder asymmetry B) Pelvic obliquity C) Rib hump D) Prominent scapula

All are true

In the hospital you see a 6 year old girl with spina bifida. You are consulted due to the patient's club foot and a 30 deg scoliotic thoracic curvature. Please circle one choice that would be part of the normal treatment for a child with spina bifida: A) Prevent contractures due to neurogenic deformities B) With hydrocephalus, decompress and place shunt in place C) Prevent pressure sores D) Fit patient with an ankle foot orthosis and a TLSO E) All of the above

All of the above

Sarmiento style fracture orthoses utilize which biomechanical principles for fracture management? Choose all that apply: A) Multiple 3-point pressure systems B) Total contact C) Long lever arms D) Hydrostatic tissue loading

All of the above are biomechanical principles of a Sarmiento fracture orthosis. Note: because these orthoses are typically bi-valved hydrostatic loading can be maintained as swelling or muscular atrophy occur by simple modifications to tighten the orthosis versus a fiberglass/plaster cast which has a fixed volume.

Choose all the pathologies that indicate the need for medial longitudinal arch support in a functional foot orthotic: A) Plantar fasciitis B) Posterior tibialis tendon dysfunction C) Knee osteoarthritis in the lateral compartment D) Pes plano valgus

All of the above are pathologies that can be treated with MLA support. A - decreases pull across plantar fascia, B - decreases work load of patient, C - unloads lateral knee compartment, D - provides neutral alignment to decrease likelihood of other pathologies.

A patient is seen in clinic. The patient presents with DX: lower lumbar stenosis and a RX: LSO align appropriately. Which option would you recommend:

An LSO aligned in flexion will allow the spinal canal to relatively decrease occlusion and whereby increase space for the spinal cord.

A patient is diagnosed with an anterior cerebral artery stroke. You may need to assist with bracing. Based on the diagnosis you can expect that the patient will present with: A) Contralateral hemiparesis, leg more affected than the arm B) Contralateral hemiparesis, arm more affected than the leg C) Ipsilateral ataxia, decreased pain and temperature to the face. D) Quadriplegia, bulbar paralysis, preserved consciousness

Anterior cerebral stroke results in the leg more affected than the arm and contralateral sensory loss. Middle cerbral artery stroke results in hemiplegia, arm more affected than the leg. Basilar artery occlusion at the pons produces what is known as locked-in-syndrome causing quadriplegia with no motor function but preserved consciousness.

During swing phase of the gait cycle what muscles are active to achieve dorsiflexion: A) Anterior tibialis, extensor hallucis longus, extensor digitorum longus B) Anterior tibialis, peronous brevis, extensor digitorum longus C) Anterior tibialis, gastroc soleus, extensor hallucis longus D) Anterior tibialis, extensor hallucis longus, tibialis posterior

Anterior tibialis, extensor hallucis longus, extensor digitorum longus

With regards to spondylolisthesis, what are the radiographic signs that contraindicate orthotic intervention and indicate a surgical candidate:

Anterior translation of the superior vertebrae over the inferior vertebrae greater than 50% and superior vertebrae angulations of 50 deg relative to the inferior vertebrae are indications to discontinue bracing and explore alternative treatments and or surgical intervention.

A 240lbs female bears how much weight collectively through her right 2nd-5th MTP joints while standing evenly on both feet: A) 20lbs B) 40lbs C) 60lbs D) 120lbs

B - A 240lbs patient when standing evenly on both feet 120lbs on each foot. 50% goes through the calcaneus and 50% goes through the MTP joints. MTP's 2-5 receive 66.6% of the total weight on the forefoot. .666X60lbs - 40lbs.

A patient wearing a KAFO is seen in clinic. The patient complains of anterior thigh pressure while sitting. What could be the cause: A) Mechanical knee joint is too proximal in relation to the anatomical joint B) Mechanical knee joint is too distal in relation to the anatomical joint C) Mechanical knee joint is too posterior in relation to the anatomical joint D) Mechanical knee joint is too anterior in relation to the anatomical joint

B - If the mechanical knee joint of a KAFO is too distal in relation to the anatomical joint the patient will experience pressure on the anterior portion of their thigh while sitting.

A patient with Duchennes Muscular Dystrophy is seen to ambulate with increased lumbar lordosis secondary to which muscular weakness: A) Hip flexor B) Hip extensor C) Hip adductors D) Hip abductors

B - Individuals with duchennes muscular dystrophy often present with weakness of the hip extensors. By increasing lumbar lordosis the position of their center of mass is posterior to the hip joint which locks the hip against the Y-ligament allowing for stability in the sagittal plane.

The lumbricals act to: A) Flex the MP joints and abduct the thumb B) Flex the MP joints and extend the IP joints C) Abduct the phalanges D) Extend the MP joints and flex the IP joints

B - Lumbricals act to flex the MP joints and extend IP joints. The interossei muscles act to either adduct or abduct the digits along with pairing with the lumbricals to flex the MC joints and extend the IP joints.

A patient is seen in clinic, You are filling in for a sick practitioner whom delivered a KAFO 1 week earlier. The patient was provided the KAFO as he has 30 deg genu recurvatum and a 15 deg fixed plantarflexion contracture. The patient states he has a hard time getting over his foot at midstance and that while his knee extension is decreased he feels excessive pressure on the posterior aspect of his knee. What adjustments or additions can you make to remedy this problem: A) Dorsiflex the ankle joint B) Add a 15 deg tapered heel wedge to the foot plate C) Recommend rocker sole shoes D) Add a contralateral heel lift

B,D - By adding a 15 deg tapered heel wedge you will neutralize the KAFO in the sagittal plane allowing for a smoother roll over at midstance. It will also be necessary to add a contralateral shoe lift equal to the height of the tapered heel wedge to maintain a level pelvis as well as to assure proper clearance of the KAFO during swing phase of gait.

A patient is seen in clinic for a follow up appointment and is disappointed with the results of his custom solid ankle foot orthotic as he still has a pronounced knee hyperextension moment during stance phase of gait. You noticed this at his last follow up and had your technician add a 1/4" heel lift to relatively dorsiflex the SAFO to decrease the knee extension moment in stance. What should your first reaction be to this: A) Re-fabricate the SAFO and incorporate increased dorsiflexion B) Check the durometer of the 1/4" heel lift your technician added C) Re-fabricate the SAFO to incorporate increased plantarflexion D) Add a SACH heel to the patient's shoe

B - Often times practitioners add a heel wedge to an SAFO to decrease knee hyperextention thrust but, the durometer of the heel wedge is most important as a soft heel wedge will cause ground reaction forces to remain anterior to the knee during loading response whereby increasing knee hyperextention. By utilizing a firm durometer for this heel wedge you can decrease the GRF's anteriorly directed and position them posterior to the knee which will promote knee flexion. NOTE: Check quadriceps strength prior to doing this as they must be able to control the flexion moment.

Damage to the femoral nerve will result in weakness of what main muscle group: A) Hip extensors B) Knee extensors C) Hip Abductors D) Ankle plantarflexors

B - The femoral nerve (L2, L3, and L4) innervates the quadriceps femoris muscle which serves to extend the knee. The hip extensors are innervated by the sciatic nerve. Hip abductors are innervated by the superior gluteal nerve. Ankle dorsiflexors are innervated by the peroneal nerve.

A patient is seen in clinic. The patient is utilizing foot orthotics with 3/8" heel lifts to decrease inflammation of her heel chord "achilles tendonitis". What lumbar pathologies could this aggravate: A) Anterior compression fractures of the lumbar spine B) L5-S1 spondylolisthesis C) DJD of the lumbar facet joints D) Lumbar Spondylolysis

B,C,D - When recommending heel lifts for achilles tendonitis recognize that it will increase lumbar lordosis. The listed lumbar pathologies are all treated by decreasing lumbar lordosis and can be aggravated by heel lifts on a relative scale.

A patient is seen in clinic. The patient is utilizing a WHFO (wrist driven flexor hinge). The patient states that she can grasp objects but cannot maintain for long periods of time due to muscular fatigue. What addition can you add to this orthosis to allow for long periods of three point palmer prehension: A) Wrist extension assist B) Ratchet lock at the wrist C) Flexion stop at the wrist D) Extension stop at the wrist

By adding a ratchet lock at the wrist, the patient can extend the wrist to the desired prehension width and lock it in place over the object while then having the ability to relax their wrist extensor muscles.

A 16 year old patient has suffered an L2 complete spinal cord injury. What would be the most likely functional expectation and orthosis for this patient: A) Ambulation using bilateral KAFOs and a walker B) Ambulation using recipricating gait orthosis C) Ambulation with bilateral AFOs and canes D) Wheelchair mobility

C - A lesion at the level of L2 would be a lower motor neuron lesion as it is a cauda equina injury. You would expect that the patient would have intact hip flexion, hip adduction, and knee extension. This patient would only need AFO's as bracing for the knee is not needed due to knee extension is still intact.

A patient is seen in clinic for a follow up appointment and is disappointed with the results of his custom foot orthotics. The patient is being treated by you for a Mortons Neuroma (between the 3rd and 4th metatarsals). The foot orthotic you provided has utilized "MLA support and Carlson modifications". What modification would be most effective to increase the effectiveness of the foot orthotics: A) Increase MLA support B) Change the top cover to a softer durometer C) Add a metatarsal pad D) Add a lateral extrinsic wedge

C - By adding a metatarsal pad you can relatively increase the distance between each metatarsal and its adjacent metatarsal whereby decreasing pressure or shear against the Morton's neuroma.

A KAFO patient is seen in clinic for follow up. The patient has utilized a KAFO for three years but has developed avascular necrosis "AVN" of the femoral condyles. What change could you make to the current KAFO to allow for minimal ambulation without slowing the reversal of AVN: A) Incorporate patellar tendon weight bearing B) Loosen thigh cuff adjacent to the femoral condyles C) Incorporate ischial weight bearing D) Lock the knee and ankle joints in the sagittal plane

C - By fabricating an ischial weight bearing brim you can load proximally while unloading distally at the femoral condyles whereby allowing for minimal ambulation while treating AVN.

A patient is seen in clinic. She presents with severe chronic bilateral posterior tibialis tendon dysfunction "PTTD". She has worn custom UCBL's in the past but they were ineffective. What would be the most appropriate recommendation given her presentation and past: A) SMO's B) Motion control pronator type shoes C) Articulated AFO D) Walking boot "off the shelf type"

C - Given that the UCBL's were ineffective, articulated AFO's would be appropriate as they grasp the lower leg and can help to modify internal tibial rotation. By decreasing internal tibial rotation, pronation will decrease whereby decreasing the work load of tibialis posterior muscle.

Having a patient perform a heel raise, screens what myotomal level: A) L4 B) L2 C) S1 D) L5

C - Having a patient plantarflex is a screening technique for S1 myotome. Often in the clinic a clinician will have a patient walk on their toes for S1 myotome screen and then walk on their heels for L4-5 myotome screen.

When turning a conventional AFO into a dorsiflexion assist AFO, how would you set up the double action ankle joint: A) Springs in the anterior channels B) Pins in the anterior channels C) Springs in the posterior channels D) Pins in the posterior Channels

C - Springs in the posterior channels will produce dorsiflexion assist in double action ankle joints

When fabricating an AFO the lateral proximal trimline is located approximately 1 inch inferior to the fibular neck. What anatomical structure are you trying to avoid by doing this: A) Fibular head B) Saphenous nerve C) Common fibular nerve D) Tibial nerve

C - The common fibular nerve "Common Peroneal Nerve" runs just inferior to the fibular head superficially. Trim lines should be designed to avoid impingement of this nerve when fabricating an AFO.

The erector spinae muscles are found in the intermediate layer of the muscles in the back. When they act bilaterally, they extend the vertebral column. When they act unilaterally what action do they perform: A) Rotate the spine B) Rotate and laterally bend to the side of active muscles C) Laterally bend the vertebral column D) Stabilize vertebrae during local movements of the vertebral column

C - The erector spine muscles act to extend the vertebral column and unilaterally act to laterally bend the column. Choice D is performed by the deep layer known as transversospinal muscles (multifidi, semispinalis, rotatores).

Trendelenburg gait can be seen in patients after they have a total hip arthroplasty, injury to the superior gluteal nerve, and poliomyelitis. This is caused by weakness in what muscle: A) Gluteus maximus B) Iliopsoas C) Gluteus medius D) Abductor magnus

C - Weakness of the gluteus medius results in trendelenburg gait. During the stance phase the pelvis on the opposite side drops due to weakness on the stance side.

A patient is seen in clinic with flaccid ankle plantarflexors and dorsiflexors. Choose appropriate double action ankle joint configurations: A) springs in anterior and posterior channels B) Pins in the posterior channels with springs in the anterior channels C) Pins in the anterior and posterior channels D) Springs in the posterior channels and pins in the anterior channels

C,D - Both of these configurations will provide anterior and posterior support for flaccid ankle plantarflexors and dorsiflexors.

A patient is seen in the hospital. The patient presents with a T11 anterior compression fracture from a bike accident. The patient is neurologically intact and the fracture is stable. Which orthosis(s) would be most appropriate:

CASH and Jewett TLSO's both are effective for anterior compression fractures near the thoracolumbar junction. By placing the thoracic spine in extension, pressure is removed from the anterior portion of the vertebral body allowing natural bone remodeling to occur.

You see a patient who describes pain in her shoulder after chopping wood. You find on physical examination weakness with shoulder flexion and you note scapular winging. The patient's problem could be accounted by what MOST LIKELY:

Continuous overhead activities can cause inflammation of soft tissues, placing pressure over peripheral nerves such as the long thoracic nerve. With compression this nerve would then cause weakness in the serattus anterior. You would note winging of the scapula especially with arm abduction greater than 90 deg. Suprascalular nerve innervates part of the rotator cuff (supraspinatus and infraspinatus) and would not cause winging. Rotator cuff tendonitis also would not cause winging, but could cause flexion weakness.

What are the characteristics of the congenital abnormality in infants called torticollis?

Contracture of the sternocleidomastoid, ipsilateral head tilt, contralateral head rotation are all characteristics of Torticollis.

When examining a scoliosis radiograph, the vertebral body is seen to rotate toward the _________ in relation to the curve and the spinous process is seen to rotate toward the__________ in relation to the curve:

Convexity, Concavity

Injury to the median nerve will result in what characteristic appearance when a patient tries to make a fist: A) Ape hand B) Claw hand C) Hand of benediction D) A and C

D - Injury to the median nerve may result in loss of opposition and flexion of the thumb resulting in the ape hand deformity. Also the hand of benediction results from injury of the median nerve at the elbow or upper arm.

The sciatic nerve innervates all these muscles EXCEPT: A) Semitendinosis B) Biceps femoris C) Semimembranosis D) Gluteus medius

D - The sciatic nerve provides sensation to most of the leg and motor function to most of the posterior leg muscles, there is a tibial division and the common fibular division that innervates the bicpes femoris. The gluteus medius is innervated by the superior gluteal nerve.

A patient is seen in clinic. The patient is utilizing a KAFO for post polio syndrome. The ankle joint height is located correctly but the mechanical ankle joint is in need of replacement for the third time. What could cause this: A) Ankle joint height is incorrect B) The ankle joint is not properly lubricated C) The patient has switched to a shoe of differing heel height D) Tibial torsion was not built into the KAFO

D - If premature wear is noticed in a KAFO ankle joint that is located at the proper height often times tibial torsion was not built into the orthosis causing a lack of congruency between the anatomical and mechanical ankle joints.

You are seeing a patient in acute rehab with a physical therapist. This patient has had a CVA. Upon examination you see foot drop during gait, weak dorsiflexors grade 2, weak inversion and eversion grade 2, and increased tone in her plantar flexors. What would be an appropriate orthotic device: A) A dorsiflexion assist B) Off the shelf carbon fiber AFO C) Spiral AFO D) A solid ankle AFO

D - A solid ankle AFO is indicated for a patient with foot drop who also has spasticity as a spiral AFO and a dorsiflexion assist AFO might increase her tone and are not sufficient to control spasticity.

A patient is seen in clinic with flaccid ankle plantarflexors and dorsiflexors. The patient also buckles at the knee during loading response/heel strike. You have chosen to recommend a conventional AFO with double action ankle joints. What would be the most appropriate configuration of the ankle joints: A) Springs in anterior and posterior channels B) Pins in the posterior channels with springs in the anterior channels C) Pins in the anterior and posterior channels D) Springs in the posterior channels and pins in the Anterior channels

D - By having springs in the posterior channels and pins in the anterior channels you will provide adequate ant/post support to the lower leg muscular imbalances but the posterior springs will allow controlled plantarflexion during loading response whereby keeping the ground reaction forces anterior to the knee joint to decrease knee buckling.

What is the most appropriate foot orthotic for a type two diabetic: A) Accommodative B) Accommodative, fabricated out of diabetic multidensity trilaminated foam with a polypropylene base C) Accommodative, fabricated out of diabetic multidensity trilaminated foam with a Medicare approved foam base layer D) Funtional/Accommodative, fabricated out of diabetic multidensity trilaminated foam with a medicare approved foam base layer

D - When fabricating a diabetic type insert it is still important to consider the individuals foot type so functional modifications may be necessary. i.e. a patient with a cavo varus foot is more likely to receive excess pressure on the lateral border of their foot. So, functional foot orthotic modifications need to be incorporated into the diabetic foot orthotic to decrease the likelihood of ulcer/callus development on the lateral border of their foot.

When taking an impression and delineation for a KAFO what landmark represents knee center: A) MTP (medial tibial plateau) B) MPT (mid patellar tendon) C) The midpoint between MTP and MPT. D) The midpoint between MTP and the adductor tubercle.

D - When taking an impression and delineation for a KAFO, knee center is represented by the midpoint between MTP and the adductor tubercle.

A patient is seen in clinic and presents with L5,S1 spondylolisthesis. The patient has handed you a script with RX: LSO aligned appropriately. How would you align the patient in the sagittal plane:

Decrease Lumbar Lordosis Decreasing lumbar lordosis causes lumbar flexion, which is the most appropriate position to prevent progression and allow for healing of the pathology

A patient is seen in clinic and presents with lumbar DJD. The patient has handed you a script with RX: LSO aligned appropriately. How would you align the patient in the sagittal plane:

Decrease Lumbar Lordosis Decreasing lumbar lordosis moves pressure off the posterior "affected" portion of the vertebrae onto the vertebral body away from the arthritic joints.

Which nerve innervates the rhomboid muscles and levator scapulae: A) Long thoracic B) Suprascapular C) Axillary D) Dorsal scapular

Dorsal scapular nerve innervates rhomboids and levator scapulae Long thoracic nerve innervates serratus anterior. Axillary nerve innervates deltoid and teres minor muscles, suprascapular innervates supraspinatus and infraspinatus muscles on the rotator cuff.

Gowers sign is seen when a person gets up from the floor, walking hands up his legs to get upright. Choose the most common diagnosis where this is seen:

Duschenne muscular dystrophy

What is the primary function of brachioradialis: A) Elbow flexion B) Elbow flexion and forearm pronation C) Elbow flexion and wrist extension D) Elbow flexion and wrist flexion

Elbow Flexion

T/F, When fabricating a Williams Flexion LSO for spondylolisthesis, the anterior corset panel should be fabricated out of an inelastic material:

False

T/F, A child wearing a Pavlic harness in treatment for congenital dislocation of the hips should have their hips oriented in flexion and adduction: A) True B) False

False A child wearing a Pavlic harness in treatment for congenital dislocation of the hips should have their hips oriented in flexion and abduction.

T/F, When designing a ground reaction ankle foot orthosis "GRAFO" foot plate length can be full foot or sulcus length: A) True B) False

False- GRAFO's tend to be fabricated with full foot plates so as to utilize a longer lever arm to resist knee instabilities throughout stance phase of gait.

T/F, A patient with a cavo varus foot and peroneal tendonitis should utilize their functional foot orthotics (1st ray relief, extrinsic lateral wedge) with a pronator motion control type shoe:

False: It is of the utmost importance to use a supinator "cushion" shoe in combination with a functional foot orthotic including a 1st ray relief and extrinsic lateral wedge. Note: as a general statement patients don't necessarily choose appropriate shoe wear to compliment their functional foot orthotics. "IT IS YOUR JOB TO HELP LEAD THEM IN THE CORRECT DIRECTION"

A patient you are working with has a medial nerve lesion, you would expect that they will have loss of all functions EXCEPT one of the following: A) Abductor pollicis brevis B) Flexor pollicis Brevis C) Opponens pollicis D) Flexor carpi ulnaris

Flexor carpi ulnaris

When evaluating to see if a scoliotic curve is non-structural what will you notice with forced lateral side bending:

Forced lateral side bending will show rotational correction for non-structural curves

What modification can you make to an ulnar fracture orthosis to increase its effectiveness at immobilizing a distal 2/3 ulnar fracture: A) Cross the elbow joint for a longer lever arm B) Increase pressure M/L for increased immobilization C) Increase pressure A/P for increased immobilization D) Add rigid aluminum stays for increased immobilization

Increase pressure A/P "interosseous membrane" creates tension between the radius and ulna. This tension is an effective immobilizer for ulna fractures.

Posterior Trim lines on an LSO extend from the sacrococcyxgeal joint to just inferior to_____________ . Anterior trim lines extend from symphysis pubis to the_____________:

Inferior angle of the scapula, xiphoid process

A brachial plexus injury occurs resulting in decreased wrist and hand function. Choose which type of brachial injury would likely be the cause: A) Erb's palsy B) Klumpke's palsy C) Trisomy 21 D) Ulnar neuritis

Klumpke's palsy

A patient is seen in clinic whom has been diagnosed with Guillain-Barre syndrome. The patient has weak knee extensors, knee flexors, ankle plantarflexors, and ankle dorsiflexors. What muscle groups would you expect to regain strength first if the syndrome begins to remit: A) Knee extensors B) Ankle plantarfexors C) Ankle dorsiflexors D) Knee Flexors

Knee extensors and flexors will regain strength first as individuals recovering from Guillain-Barre regain motor function proximal to distal.

In normal gait, maximum knee flexion reaches approximately: A) 30-35 degrees B) 35-40 degrees C) 45-50 degrees D) 60-65 degrees

Knee flexion during swing phase is 60-65 degrees in the normal gait cycle

You are working with a therapist on gait training for a patient that has a L1 complete spinal cord injury along with another patient that has an L4 spinal cord injury. What bracing would you expect most appropriate for these patients and ambulation tolerance respectively:

L1 spinal cord injury: Independent ambulation with knee ankle foot orthosis (KAFO) household distance, L4 spinal cord injury: ankle foot orthosis, community ambulator independent

When selecting anterior pin placement in a HALO CTLSO application, where is the proper starting position:

Lateral 1/3 of eyebrow, slightly superior to eyebrow

When you are working with a patient with left hemiplegia you would expect that they would be least likely to respond to you if you were emphasizing: A) Maximum use of demonstration and gesture B) Simple verbal cues C) Minimizing open ended questions D) Simplification of treatment

Maximum use of demonstration and gesture A patient with left hemiplegia has difficulty with sequencing, producing language, difficulty processing information and will have visuospatial deficits. Maximum use of demonstration and gesture would not be appropriate.

A patient is seen in clinic. The patient presents with a midshaft humeral fracture (10 deg of varus is noted at the fracture sight). What orthosis would you recommend:

Midshaft humeral fractures can be managed with a Sarmiento humeral fracture orthosis. Long term benefits of the Sarmiento: Micro motion at the fracture site promotes bone growth. Movement at the elbow throughout the healing process minimizes stiff elbows that require extensive rehab. Movement of the arm, once comfortable, promotes muscle pump action to aid circulation.

When taking an impression for a custom polymer LSO for a patient with L5, S1 spondylolisthesis, how would you position the patient if they were allowed to stand through the procedure:

Patient should be asked to flex their hips and knees slightly. (reduces lumbar lordosis)

The definition of _________, is a cranial asymmetry "nonsynostotic origin" caused by external forces and sometimes attributed to the SIDS:

Plagiocephaly is a deformity of the cranium that is usually rhomboid in shape when viewed in the transverse plane. If caught early it can be managed with a cranial remolding helmet.

A patient is seen in the hospital. The patient presents with a L1 burst fracture from a snowmobile accident. Which orthosis would be most appropriate:

Polymer TLSO Burst fractures are most unstable in the transverse plane. A custom polymer TLSO is most effective at rotational control and has the proper coverage.

You have a patient that presents for evaluation for an AFO after a stroke. You notice he has a forward flexed posture. What positive muscle length test would you expect to see associated with this posture:

Positive Thomas test tests for iliopsoas (hip flexion) tightness. Often with hip flexor contractures the patient will present with a forward flexed posture when standing.

Scoliosis is sometimes sub-divided into different types. What are signs of neuromuscular scoliosis:

Right lumbar and left thoracic curves are often signs of neuromuscular scoliosis.

Parkinson's disease is a chronic, progressive disease of the CNS with degeneration of dopaminergic neurons. What are the four hallmark symptoms: A) Rigidity, bradykinesia, tremor, and impaired postural reflexes B) Rigidity, bradykinesia, tremor, and ataxia C) Rigidity, tremor, radiculopathy, and impaired postural reflexes D) Rigidity, tremor, festinating gait, and Lhermitte's sign

Rigidity, bradykinesia known as slowed movement, tremors usually pill rolling tremor, and impaired postural reflexes are the classic symptoms of Parkinson's disease. Radiculopathy is a peripheral nervous system dysfunction. Lhermitte's sign can be seen with other upper motor neuron disorders such as multiple sclerosis but not Parkinson's disease.

A patient is seen in clinic. The patient presents with a separated connective tissue in her symphysis pubis. What orthosis is recommended and what hormone can cause the elasticity of the symphysis pubis to increase during pregnancy:

SI Belt and the Relaxin hormone Relaxin is a hormone that is released in pregnant women which increases the elasticity of connective tissue to assist the ease of birth. In some cases the pubic symphysis can become too elastic causing pain and instability so a SI belt is utilized to provide increased stability to the pubic symphysis joint.

A patient with a diagnosis of Brown Sequard Syndrome (SCI) which occurred at C4 affecting his right upper extremity and right lower extremity comes to your clinic for an LE orthosis. He is ambulatory but requires minimal assistance. Initially, what assistive device would be most appropriate and in what extremity:

SPC "single point cane" on the unaffected side to counterbalance the loss of function on the right.

Posterior trim lines on a TLSO extend from the sacrococcygeal joint to just inferior to_____________ . Anterior trim lines extend from symphysis pubis to the_____________:

Scapular spine, sternal notch

A 15 year old scoliosis patient is seen in clinic for her initial evaluation. After cobbing her x-ray, you and her physician agree that that she has a 20 deg left lumbar, 22 deg right thoracic curves with no signs of progression. What should your treatment consist of at this time:

Scoliotic curve of a magnitude less than 25 deg indicate a treatment plan of observation and follow up. NOTE: In some cases with very young patient's earlier management may be indicated due to a lack of skeletal maturity.

A scoliosis patient is seen in clinic for her initial evaluation. After cobbing her x-ray, you and her physician agree that she has a 35 deg left lumbar curve with no signs of progression. What should your treatment consist of at this time:

Scoliotic curves of magnitude 30-45 deg should be managed with an orthosis immediately, regardless of progression.

Why is Sheurmann's kyphosis typically easier to manage with an orthosis compared to scoliosis:

Sheurmann's Kyphosis only has a sagittal plane component of deformity, whereas scoliosis has both sagittal and transverse plane components of deformity making it relatively more difficult to manage with an orthosis.

Which types of scoliotic curves would you expect to progress more given only the location of the curve:

Single lumbar and thoracolumbar scoliotic curves have been shown to progress more in relation to thoracic and double major curves.

When selecting posterior pin placement in a HALO CTLSO application, where is the proper starting position:

Slightly superior to ear, opposing the anterior pin directly, inferior to equator of the cranium

It is early in the recovery phase of a patient with a L3 compete spinal cord injury. The expected outcome would MOST likely be:

Some recovery of function since damage is to peripheral nerve roots.

A patient with an upper motor neuron disorder has a posterior loss of balance with immediate sit to standing due to either tight muscles or weakness. What would be the most likely cause of this:

Spasticity of the gastrocnemius-soleus The muscles around the ankle provide ankle strategies, the gastrocnemius-soleus moves the body posterior while anterior tibialis helps move the body anterior.

What pathology would indicate the use of a Williams Flexion LSO:

Spondylolisthesis The Williams Flexion LSO allows free lumbar flexion but stops lumbar extension.

A scoliosis patient is seen in clinic. Upon radiographic reading you note that the thoracic curve apex is located at T6. Which orthosis is appropriate:

The Milwaukee CTLSO system is utilized for scoliosis curves T7 and higher. In some instances additions can be built into a Boston system to simulate the effectiveness of a Milwaukee system which can increase patient comfort and compliance.

How do you measure the anatomical waist?

The anatomical waist is measured by finding the distance between the inferior costal margin and the iliac crest, and then divide by two

You see a patient with wrist drop, paralysis of the triceps, brachioradialis, supinator, and extensor muscles of the wrist and digits. What nerve is responsible for this and where likely is the injury: A) Radial nerve; distal elbow B) Median nerve; radial groove C) Radial nerve; superior to the triceps brachii muscle D) Ulnar nerve; shoulder joint

The radial nerve innervates the wrist extensors and injury will cause wrist drop. If the injury causes triceps weakness then the clinician would conclude that the injured nerve occurred proximal to the tricipes brachii muscle, injury within the radial groove the triceps usually is not completely paralyzed

Injury to the tibial nerve on the right leg, would cause which gait deviation:

The tibial nerve innervates muscles on the posterior leg (i.e triceps surae, posterior tibialis etc) which will cause decrease push off during gait along with shortened step length on the contralateral side. Foot drop would be seen with injury to common fibular nerve which innervates anterior tibialis.

The radial nerve is injured within the radial groove. What muscle would NOT be paralyzed: A) Triceps B) Supinator C) Brachioradialis D) Extensor carpi ulnaris

The triceps muscle is innervated by the radial nerve, but when injury occurs at the radial groove usually it is just weakend not paralyzed. All the muscles in the posterior compartment will be paralyzed leading to wrist drop.

With a traction injury to the anterior division of the brachial plexus you would expect, weakness of the elbow flexors, wrist flexors and forearm pronators. What other muscle group would you expect to be weak:

Thumb abductors

T/F, An RGO allows forward progression by harnessing energy from one hip's extension and translating it into contralateral hip flexion: A) True B) False

True By harnessing energy from one hip's extension and translating it into contralateral hip flexion an RGO can facilitate forward progression.

T/F: The duration of double support varies inversely with the speed of walking and in running double support is absent: A) True B) False

True In slow walking double support increases compared to the swing phase.

T/F, A patient with a pes plano valgus foot and peroneal tendonitis should utilize their functional foot orthotics (MLA support, extrinsic medial wedge, and or carlson modifications) with a pronator motion control type shoe:

True: It is of the utmost importance to use a pronator "motion control" shoe in combination with a functional foot orthotic including a MLA support, extrinsic medial wedge, and or carlson modifications. Note: as a general statement patient's don't necessarily choose appropriate shoe wear to compliment their functional foot orthotics. You should steer them in the right direction.

T/F, Guillain-Barre syndrome progresses in an ascending order: A) True B) False

True: Guillain-Barre syndrome progresses in an ascending order "distal to proximal" and recovers in a descending order "proximal to distal".

T/F, When fabricating a KAFO the distal/posterior thigh band and the proximal/posterior calf band should be located equidistant from the knee axis: A) True B) False

True: When fabricating a KAFO the distal/posterior thigh band and the proximal/posterior calf band should be located equidistant from the knee axis so as not to impede knee flexion and soft tissue impingement in the popliteal fossa.

Scoliosis is sometimes sub-divided into different types. What are signs of congenital scoliosis:

Wedged, bar, and hemi-vertebrae

When fabricating a rancho style HO (hand orthosis) , what length would you terminate the thumb post at: A) 1st digit IP joint B) 2nd digit mid finger nail bed C) 1st digit MP joint D) 1st digit mid finger nail bed

When fabricating a rancho style HO the thumb post is terminated at the 1st digits mid nail bed so as to avoid interference with prehensile activities.

A patient is seen in clinic. DX: Sheurmann's Kyphosis apex= T9, RX: Orthosis. What type of orthosis would you recommend:

When managing a patient with Sheurmann's Kyphosis, apex locations of T8 or lower are managed with a custom TLSO and apex locations of T7 or higher are managed with a custom CTLSO.

A patient is seen in clinic. The patient presents with her right radial nerve intact and severed median and ulnar nerves. What orthosis would you recommend: A) Rancho style HO B) WHFO (wrist driven flexor hinge) C) Static WHFO. D) WHO (in anatomical position)

With the radial nerve intact, the patient will still have extensor motion available. A wrist driven flexor hinge will capture that extensor motion and translate it into natural tenodesis to grasp objects with three point palmer prehension.

When applying a HALO CTLSO for pediatric applications, how may your protocol differ from adult applications:

use more halo pins, use less torque