U gone pass
Describe the four levels of sensation risk classification
0- no LOPS 1- LOPS w/o deformity or history of ulcer 2-LOPS and deformity and abnormal blood flow w/o history of ulcer. 3- history of plantar ulcer
Hypokyphosis range
0-20*
1. What is the mechanism of injury for a Seat belt fracture? 2. What is another name for it?
1. Flexion and distraction 2. aka "Chance fracture"
Which curve magnitudes (1) and types (2) are more likely to progress?
1. Greater than 30 degrees 2. Single thoracic and double curves
How is a foot stress fracture treated?
foot in initially immobilzed with a CAM walker a foot orthosis is then used to transfer weight to the first met from the lesser mets
Why do we have 20 degrees of flexion during stance
for energy efficiency limit up and down motion of CoG
Why is an automatic lock feature wanted by some patients
for the audible sound of the lock engaging reassuring for patients
Why do we use clamshell design for fracture bracing
for the intimate fit, contain as much soft tissue as possible
Why do we use thermoplastic for a fracture brace
for the intimate fit, contain as much soft tissue as possible
excessive pronation often have what related devications? and what two mods to make to reduce this deviation
forefoot abduction, calcaneal valgus, patient states they have 1st met head discomfort. 5th met head containment and medial sabolich mod
What is a scotty dog fracture?
fracture of the pars interarticularis hyperextension injury want to decrease lodorsis
What is a hangman's fracture?
fracture though the lamina of the axis
What is a Salter-Harris fracture?
fractures of the growth plate in children (epipheseal plate)
If the knee lock is disengaged, what is the knee classified as
free knee joint
proximal thigh trimlines of a KAFO
from greater trochater to femoral condyles
boxers fx
fx of 5th metacarpal
Two surgical techniques for plantar fascitis
gastroc lengthening and plantar fasciia release
how can you control varus/valgus with a PLS?
gillette modification with intimate control of the heel
What type of patient would be a good candidate for ankle activated stance control knees
good for patients who are really unstable someone with antalgic gait potentially
purpose of sole flare
greater stabiliy and resistance to inversion/eversion of the foot
What are some negatives to stance control knees
hard to get reimbursement weight, size, bulk they are very large
What hormone can cause elasticity of the syphysis pubis during pregnancy?
relaxin hormone
where does the GRF pass at the ankle knee and hip during early stance? What moment does that cause?
through the ankle, behind the knee, through the hip causes a flexion moment
C8 myotome
thumb extension
Patient keep having premature wear of the ankle joints on a KAFO. What could be the cause
tibial torsion what not built into the kafo
Deep peroneal nerve
tibialis anterior extensor digitorum longus extensor hallucis longus peroneus Tertius extensor digitorum brevis
How do you adjust the amount of dorsi flexion assist in a double action ankle joint?
tighten the screw to compress the spring more or loosen it decompress the spring
The Primary goal of a corrective scoliosis orthosis in the treatment of moderate adolescent idiopathic scoliosis is:
to prevent progression of the curve
when would you use a full footplate?
tone or spasticity present caw toes, hammer toes, or toe grasp mid foot fx
A burst fracture is the most unstable in what plane?
transverse
Which plane are burst fractures the most unstable in?
transverse
muscles involved in upward rotation
traps and serratus anterior
What muscles stabilize vertebrae during local movements of the vertebral column?
traversospinal muscles
What is gowers sign and what disease is it associated with?
using hands to stand up by pushing off lower extremities. Common in Duchennes muscular dystrophy
What forces are acting on the knee during single limb stance?
valgus thrust on knee secondary to lateral shift
hindfoot ROM
varus and valgus 5 degrees
Femoral Nerve
vastus lateralis rectus femoris vastus medialis vastus intermedius illiacus sartorius pectineus
define spasticity
velocity dependant state of hypersensitivity
What system is responsible postural tone?
vestibular system
what should you do before removing the cast?
vetical line down the cut strip horizontal lines to key in the cast inform patient of the function of the cast saw
Can you use a lever lock or drop lock with a posterior offset joint
yes, may use drop lock on top to guarantee they are stable
If you have a Medicare Contract, what do you charge the patient?
you accept medicare fee schedule amount as full payment
How does a drop lock knee joint work? When may you not want to use it?
• Automatic Lock via gravity • Can be used with ball retainers to prevent locking • Manually unlocked • Modified form available to protect clothing • Hard to unlock when loaded (spasticity)
"Ape hand" position
- thumb is found in the plane of the palm - thenar atrophy
Paresthesia
- tingling - burning - pins and needles
What muscles does the radial nerve (C6, C7, C8, T1) innervate?
- triceps brachii - anchoneus - brachioradialis - extensor carpi radialis longus Deep branch: - the remainder of the extensor muscles plus supinator muscles of the forearm - sensory information to the dorsal surface of the arm, forearm and hand
What motor signs would you expect from a combined median and ulnar lesion?
- wrist hyperextension and redial deviation - "Ape hand" - MCPJs are hyperextended - PIPJ and DIPJ flexed - flexion not possible - cannot abduct or adduct the fingers
What are some accommodations we make for genu recurvatum patients through KAFOs
-All orthotic knee joints have a built in 180o extension stop. -Shallow distal thigh and calf bands -Trimlines - Thigh - High anteriorly and low posteriorly - Calf - High posteriorly (can not interfere with knee flexion to 105 degrees) -Posterior knee strap (cris-cross)
How is a conventional shoe fit to the patients shoes
-Attached to shoe, each pair of shoes needs to be modified -caliper box is for the ease of changing shoe solid stirrup is perminently attatched in shoe -Need to be careful that the split stirrup doesn't pop out of shoe due to talar angle moments If this occurs put notch in the bottom of stirrup Drill split stirup into insert of shoe
What part of the gait cycle is a posterior offset joint helpful for
-Enhances stance stability in full extension -provides stance control/stability from midstance to terminal stance and is unstable IC to MS -Use of W.B. design enhances performance
unhappy triad includes what structures
ACL, MCL, medial meniscus
For maximum efficiency, how far is the toe above the ground in swing phase?
1 cm
How far should the HALO ring be above the ears and eyebrows?
1 cm
On a pedatric HALO how much torque should be used on the pins?
1 in/lb per year
LSO superior edge of paraspinal bars
1" inferior to the inferior angle of the scapula
What motor signs relate to ulnar lesions (C8, T1)?
1) "claw hand" 2) inability to extend middle and distal phalanx of the fingers 3) inability to adduct or abduct the fingers or oppose all the fingers 4) inability to adduct the thumb, compensates with flexion (Froment's sign) 5) At the wrist: flexion weak, ulnar abduction lost, ulnar reflex lost
What tendons are inflamed with DeQuervain's Tenosynovitis?
1) Extensor pollicis brevis 2) Abductor pollicis longus
What are two tests for carpal tunnel syndrome?
1) Phalens - push the dorsums of the hands together - pain on ventral hand and forearm 2) Tinels - lightly tapping over the nerve to illicit a pins and needles sensation
What are the objectives of orthotic interventions in upper extremity conditions?
1) Reduction of pain and inflammation by restricting motion 2) Prevention of dysfunctional contractures by maintaining the joint(s) in optimal alignment 3) Prevention of stress to the joints during functional activities 4) Provision of stability for the joint(s) to improve function 5) Correction of reduction of joint contractures
Provide the anatomical location that determines the elbow axis:
1) medial epicondyle (frontal plane) 2) Bisecting line between mid upper and lower arm
What are the three requirements for a free knee brace?
1) near vertical hip-trunk alignment, 2) absence of knee flexion contracture 3) a foot that rests on the floor.
What are the three most common locations for foot ulcers?
1. 3rd met, 2. Big toe, 3. 1st and 5th met
Name 3 goals for idiopathic scoliosis treatment.
1. Achieve spinal balance 2. Prevent curve progression 3. Reduce curve in-brace by at least 50%
Erector spinae muscles function as
Extensors of the spine, lateral flexors individually
What orthotic recommendation would you give someone with a SCI with C5 escape?
External power to orthosis to flex wrist and hand
What movements can result in upper brachial plexus injury?
Extreme or violent lateral flexion of the head * especially if the shoulder is simultaneously depressed penetrating woulds, falls, humeral fractures and surgery
What movements can result in upper brachial plexus injury?
Extreme or violent lateral flexion of the head * especially if the shoulder is simultaneously depressed penetrating woulds, falls, humeral fractures and surgery - difficult delivery - these movements place large a stretch on the C5 and C6 nerve roots and /or upper trunk itself
For the treatment of plagiocephaly, who has to approve of the treatment?
FDA
T/F. Dry Gangrene exhibits a poorly defined line of demarcation
False
Correct genu valgum
Forces: lateral thigh, lateral foot, medial condyle of femur
The majority of ulcerations occurs in what region of the foot?
Forefoot
What compensatory motion would most likely be seen in an individual with quadriceps weakness?
Forward trunk lean
Quadriceps Femoris
Four parts - only one of which crosses the hip, Extensor of the leg, inserts into the tibial tuberosity
Bennett's fracture
Fracture at base of first metacarpal
Define spondylolysis and give method of injury
Fracture of pars interarticularis Caused by spinal hyperextension
What are the codes for single uprights in KAFOs
L2034, L2037, L2010
What spinal level is the waist at?
L3
Illiac crest is located at what spinal level?
L4
KAFO's are seldom prescribed for paraplegic pts w/ lesions above
L5
Correct distal trimline of the opponens bar
Proximal to the 1st MCP
The opponoens bar should be located
Proximal to the thumb MP joint
Lumbar Plexus
Psoas major Psoas minor Quadratus lumborum
What modification would you make to an orthosis for a rigid plantar flexed first ray deformity? (1)
1. First ray cut-out
Klumpke's paralysis
- results from a lower brachial plexus injury to C8 and T1 - leads to loss of intrinsic hand muscles and long finger flexors - "claw hand" deformity
What are some common causes of radial nerve palsy?
- shaft of humerus fracture - nerve compression, "honeymooners" palsy or poor fitting crutches * can be involved in ether a cervical cord (C6-T1) injury and brachial plexus injury - shoulder dislocation
How do we control the limb in the transverse plane with our KAFO
- KO may be converted to KAFO to control rotation of the orthosis on a fleshy limb. -Double upright provides best control -Torsional stiffness is critical
Boutonniere deformity
- PIPJ flexed - DIPJ hyperextended - MCPJ extended
What are the trimlines for a genu recurvatum KAFO (conventional)
- Thigh - High anteriorly and low posteriorly - Calf - High posteriorly (can not interfere with knee flexion to 105 degree)
Swan neck deformity
- contracture of the intrinsic hand muscles - PIPJ hyperextended - DIPJ flexed - MCPJ flexed
What muscle does the axillary nerve (C5 and C6) innervate?
- deltoid - teres minor - skin over distal portion of deltoid
What actions are hindered do to musculocutaneous palsy?
- elbow flexion - weakened forearm supination
Carpal tunnel syndrome
- entrapment of the median nerve as it passes into the wrist below the transverse carpal ligament - results in a paresthesia and pain to the palmar section of the lateral hand - severe form will lead to atrophy of the thenar muscles
What movements lead to lower brachial plexus injury?
- extreme abduction of the arm eg. when someone falls and grabs something above them to stop their fall - delivery when a baby is pulled by their arm from the birth canal - places extreme stress on C8, T1 and/or lower trunk causing injury
What muscles are innervated by the ulnar nerve (C8, T1)?
- flexor carpi ulnaris - ulnar 1/2 of the flexor digitorum profundus - adductor pollicis - 3rd and 4th lumbricals - palmar and dorsal interossei Hypothenar muscles - abductor digiti minimi - flexor digiti minimi - opponens digiti minimi
What muscles are innervated by the median nerve (C6, C7, C8, and T1)?
- flexor pronator muscles of the forearm: * all except for flexor carpi ulnaris and ulnar head of flexor digitorum profundus - 1st and 2nd lumbricals Thenar muscles: - abductor pollicis brevis - flexor pollicis brevis - opponens pollices (except adductor pollicis) Skin of palmar aspect of thumb and lateral 2 1/2 fingers - distal ends of the same fingers
What injuries can lead to lesions affecting the ulnar nerve?
- fractures and dislocations of the head of the humerus and at the elbow - entrapment as it passes behind the medial epicondyle of the humerus * leads to "tardy ulnar palsy" - fracture to the medial epicondyle * leads to "claw hand"
Sign of Benediction
- high median nerve injury, proximal to elbow - active sign * unlike "claw" or "Ape" hand - when someone tries to make a fist
What are some signs of sensory nerve damage?
- loss of sensation - paresthesia
What nerve(s) are damaged with an intrinsic minus hand?
- medium and ulnar nerve
4 mods to a kafo to help control knee hyperextension
-Extending the dist/post thigh trimline more distally - Decreasing the depth of the thigh section -Extending the prox/post calf trimline proximally - Decreasing the depth of the calf section
How is the Conventional KAFO fabricated
-Fabricated from measurements and tracing (no casting involved)
What presentation will you have with a genu recurvatum patient
-Often secondary to chronic quad weakness. -why they go into hyperextension for stability as the quads aren't strong enough
How do you test for a "Normal" muscle grade for: Gastrocnemius?
-Pt is prone with feet off table -Stabilize leg proximal to ankle with knee extended and ankle in DF -Pt will plantarflex the ankle through full ROM -Apply resistance to posterior calcaneus in direction of DF
How would you test for "Normal" muscle strength for: Soleus?
-Pt is prone with feet off table -Test knee is flexed to at least 45 degrees -Stabilize proximal to the ankle -Pt plantar flexes through full ROM -Apply resistance to posterior calcaneus to dorsiflex the ankle
How would you test for "Normal" muscle strength for: Tibialis Posterior?
-Pt is side lying on test side with foot off table -Stabilize lower leg proximal to the ankle -Pt inverts the foot through full ROM with slight plantarflexion -Apply resistance on the medial border of the forefoot
How would you test for "Normal" muscle strength for: Tibialis Anterior?
-Pt is sitting, ankle is in plantarflexion -Support the lower leg and stabilize proximal to the ankle -Pt dorsiflexes and inverts foot through full ROM (keeping toes relaxed) -Apply resistance on the dorso-medial aspect of the forefoot
What are some material considerations in terms of radius of curvature with KAFOs
-Radius of curvature for aluminum must exceed 6 times the thickness of the upright. -3/16" upright should not be bent smaller than 1-1/8" radius -For stainless steel, the radius is 1 times the thickness
Why would we use a Conventional KAFO
-Responds well to changes in leg volume -fluctuating edema
medial longitudinal arch support
-applys upward and laterally directed force to support the medial longitudinal arch -diminishes stress on the foot, ankle , and knee
Medicare covers AFOs and KAFOs for patients who are ambulatory who.....
-cannot be fit with a prefab afo -condition is expected to last more than 6 months -need to control the knee ankle or foot in more than one plane -patient has a documented neurological, circulatory, or orthopedic status that requires custom -has a healing fracture which lacks normal anatomical integrity
toe crest
-cresent shaped pad placed behind the 2-4 toes -transfers force from toes to sulcus
Rx for arthrodesis
-cushion heel rocker bar met pad
Primary indications of an articulated afo
-drop foot -extensor tone -type 1 hemiplegia -spastic diplegia -post-op patient with changing clinical
What movements lead to lower brachial plexus injury?
-extreme abduction of the arm eg. when someone falls and grabs something above them to stop their fall - delivery when a baby is pulled by their arm from the birth canal - places extreme stress on C8, T1 and/or lower trunk causing injury
metatarsal pad
-increases load on metatarsal shafts -Approximately .2-.5 cm in height
Knee joints will not fully lock what are some causes?
-make sure drop locks arent upside down -make sure mechanical knee center is aligned with knee axis -make sure theres not excessive torque on knee -when patient is trying to fully extend (joint alignment could be off -excursion lengths could be off on a mechanical SCO joint (one joint locks too quick and the other too slow)
what are some ways to reduce tone with an AFO
-met bar -mechanism to encourage toe extension -additional loading on either side of the distal point of the attachment of the achilles -ankle held in subtalar neutral and dorsiflexed position
How would you orient a patient in subtalar neutral?
-palpate both sides of the talus, -grasp the forefoot along the met heads with thumb and index finger, -manipulate the forefoot side to side until both sides are equally prominent
How to perform Posterior Drawer Test?
-patient in supine -foot stabilized on table -gently push the tibia back
How to perform an anterior draw test
-patient supine -foot stabilized on table -hold tibia gently with thumbs anteriior -gently pull the tibia toward you -6mm max any more is a damaged acl
Contraidications of an articulated afo
-severe coronal plane instability -desire for cosmesis - very heavy duty wear -desire for controlled flexibility -resistance to DF
shoe mod for arthritis
-soft upper -rocker bar met bar cushion heel
How to perform a varus/valgus stress test
-subject in supine with knees fully extended -stabilize foot and ankle with body -support the thigh and calf -medially directed stress at knee to check for MCL -laterally directed stress for LCL
purpose of met bar shoe mod
-transfer pressure from head to the metatarsal shafts flatter than rocker bar -more contact with the floor but less assistance with rollover.
Whats the height of a heel wedge?
.2cm-.5cm (1/8-1/4)
Describe the Wagner Ulcer Grades
0- Skin intact 1-superficial ulcer 2-deep ulcer to tendon or bone 3- Ulcer has abcess or osteomyelitis 4- gangrene on forefoot 5- gangrene over majority of foot
What modifications could you make on an AFO for a flexible VARUS deformity? (2)
1. Add a lateral "tab" just proximal to the malleolus (aka Sabolich mod) 2. Extend medial footplate trimline to encompass the 1st met head
Which (2) muscle groups does a GRAFO assist?
1. Ankle plantar flexors 2. Knee extensors
With spondylolisthesis what the the two indications for surgery not orthotic treatment?
1. Anterior transplation of the superior vertebrae over the inferior vertebrau greater than 50% or superior vertebrau angulations of 50 degrees relative to inferior vertebrae.
Name the seven steps to vascular evaluation
1. Appearance of the wound base. 2. Size of the wound. 3. Depth of the wound. 4. Infection load in or around wound. 5. Palpable pulse. 6. Capillary Refill. 7. HBO
Which vertebrae is affected in a Jefferson's fracture? What is the treatment?
1. C1 fracture 2. HALO
1. What structure is affected in a Hangman's fracture? 2. What is the treatment if stable? 3. What is the treatment if unstable?
1. C2 pedicle 2. if stable: CTO 3. if unstable: HALO
A custom AFO/KAFO must have one of what 5 requirements in addition to the non-ambulatory requirements for medicare?
1. Could not be fit with pre-fab, 2. Condition expected to be permanent or longstanding (more then 6 months), .3. Need for control in more then one place 4. documented neurologic, circulatory, or orthopaedic requires custom to prevent tissue injury. 5. Pt has healing fracture that lacks normal anatomy or proportions.
Name 4 deficits helped by the use of a dorsiflexion stop joint configuration.
1. Hip and knee flexion contractures 2. Moderate to severe DF spasticity 3. Posterior compartment injuries (ex. achilles t. rupture) 4. Weak posterior compartment, quads, and hip extensors
Name the 8 phases of gait
1. Initial Contact 2. Loading response 3. Mid stance 4.Terminal stance 5. Preswing 6. Initial Swing 7. Midswing 8. Terminal Swing
1. Which spinal orthoses utilize hyperlordosis (2) 2. Why? 3. How?
1. Jewett and Cash 2. Decreases flexion, which reduces compression on anterior vertebral bodies and limits distraction of posterior elements 3. Three-point pressure: One force applied anterior and two applied posterior
Name the five steps in a musculoskeletal exam
1. Joint integrity 2. Range of motion 3. Skeletal Deformity 4. Muscle strength. 5 Gait
Describe 3-point pressure system on UCBL for pes VALGUS/pronation?
1. Lateral directed force at arch 2. Medial directed force at lateral calcaneus 3. Medial directed force at head of 5th met
Describe the 3-point pressure system on UCBL for pes VARUS/supination.
1. Medial directed force on shaft of 5th met 2. Lateral directed force on medial calcaneus 3. Lateral directed force on head of 1st met
1. What is the mechanism of injury for a Burst fracture? 2. What is a secondary risk?
1. Spinal compression with flexion 2. Retropulsion of bony fragments in middle column could cause SCI
What are the 4 requirements for an AFO to be covered through Medicare for Non ambulation?
1. PF contracture of at least 10 degrees? 2. Expectation to correct contacture 3. contracture interfering with functional abilities. 4. Used with stretching therapy program. OR Pt has plantar fasciatis
Name 5 observations and 1 test when evaluating for scoliosis?
1. Pelvis unlevel 2. Shoulders unlevel 3. Arm gap present 4. Wrists unlevel 5. Shoulders rotated Test: Adam's forward bending
Describe 3-point pressure system for Ground Reaction AFO.
1. Posterior directed force at tibial plateau 2. Superior directed force at plantar aspect of calcaneus 3. Superior directed force at plantar aspect of footplate and toes
Where is the Center of Gravity located in relation to the following joints? (sagittal plane) 1. Hip? 2. Knee? 3. Ankle?
1. Posterior to hip (extension moment) 2. Anterior to knee (extension moment) 3. Anterior to ankle
1. What is a Risser sign? 2. What does it indicate?
1. Presence of mature growth centers on radiograph of the iliac crests (or the hand) 2. Indicates likelihood of progression -Correction best suited at grades 0-2
What are the 6 secondary diagnosis required (in addition to diabetes) to have shoes and inserts covered by Medicare?
1. Previous foot amputation. 2. History of foot ulceration. 3. Pre-ulcer callouses 4. Peripheral nephropathy with callous 5. foot deformity 6. Poor circulation
What 4 indications will get a LSO or TLSO covered by medicare?
1. Reduce pain by restricting motion. 2. Facilitate healing after injury. 3. Facilitate healing post surgery. 4. Support weak or deformed spine. ** Body sock is not covered.
What rotational prominences will appear during Adam's forward bending test for- 1. Thoracic curve? 2. Lumbar curve?
1. Rib prominence 2. Paraspinals of lumbar vertebrae
1. What is the mechanism of injury for a Compression fracture? 2. Where is the instability and why?
1. Spinal flexion with compression 2. Anterior vertebral bodies affected, tension may cause failure of posterior ligaments
Name the three tasks of gait
1. Weight acceptance, 2. Stance limb progression (single-limb support), 3. Swing Limb Advancement
Explain cobb angles
1. locate vertebrae at top of curve which has the most tilt 2. Draw a line at superior aspect of vert (towards concavity) 3. FInd inferior vert and draw line on inferior aspect 4 draw perpendicular lines so they cross 5. measure the angle of the corssed lines
Widths for calf band on a conventional AFO?
1.5 or 2 inches
PLS trimlines
1.5" distal to fib head behind the malloli by 1//4" can be sulcus or full length
Semi-Solid AFO trimlines
1.5" distal to fib head through the center of the malleoli trimline proximal to met heads unless varus and valgus control is needed footplate can be sulcus or full
solid ankle afo trimlines
1.5" to distal fib head anterior malleoli trimline shoe be proximal to the met heads unless they need varus or valgus correction foot plate can be sulcus or full length
What is the proper width of the opening for a TLSO or LSO?
1/2" to 3 1/2" gap or overlap if bivalve
what is proper shoe length?
1/2" to 3/4" past longest toe
How much do you extend a CROW boot toe and why
1/2-3/4", prevent impingement in weight bearing
How much of the weight distibuted to the forefoot is borne through the first met?
1/3
max height of lift you can place into a shoe
1/4"
What are options for upright dimensions
1/8" x 1/2" C 3/16" x 1/2" C 3/16" x 5/8" B 1/4" x 5/8" B 3/16" x 3/4" A 1/4" x 3/4" A
In Medicare, a pt must have what ROM to be a condidate for a locking knee prefab KO
10 degrees
The proximal portion of a PTB-AFO is set to what sagittal plane alignment
10 degrees of flexion
During late stance, how much hip extension for normal function
10*
Max malalignment of tibial fx
10* varus/valgus, 20* anterior/posterior
What are the normal accepted ROM for calcanea inversion and eversion?
10-20 degrees eversion 20-30 degrees inversion
What ROM is required at the knee for using stairs?
100 degrees
Malleoli M/L is 90mm, what is the inside dimension of ankle joints
101mm
What degree of flexion do we look for our KAFO to have
105
Which ribs are floating ribs?
11-12
WHat would be the orthotic treatment and expected ambulation for an L4 complete spinal word injury?
AFO (weak ankle dorsiflexors, anterior tibialis)-> Foot drop. Community ambulator
what orthosis would you expect an L4 SCI patient to need
AFO for foot drop
What are the typical healing times for hindfoot, midfoot, and forefoot charcot foot
12, 9, and 6 months respectively. Acute stage is 5 to 10 degrees hotter then other foot
A unilateral pelvic band should be what percentage fo the circumference
33%
Charcot-Marie Tooth orthosis
AFO w/ MLA support
Hemiplegic pt w/ 0 hip extensors, fair quads, and 0 calf. Recommend what
AFO w/ PF stop
what would be the functional expectation of a 16 year old patient with an L2 complete spinal cord injury?
AFOs because knee extension is still intact
What braces would you use for an L4 SCI patient?
AFOs with a posterior stop and 15 degrees of dorsi flexion.
Knee flexion ROM, starting position, axis
135 degrees, prone, lateral condyle
What orthotic recommendation would you have for someone with a zig-zag deformity?
Functional WHO, gauntlet, leather or plastic design
name a disease that affects both the pns and cns
ALS
What are examples of extension assist joints
G-knee GXL-knee Ultraflex (non-ambulatory)
what is normal tibial torsion
15 -20 degrees external
MP stop should stabilize the MP joints in _____* flexion
15*
What anatomical deficit is related to a SCI with C6 escape?
Loss of pronation wrist flexion, finger flexion and extension (only ext. carpi radialis L&B left)
Describe the Birke Risk Categories
For the neuropathic foot. 0-Has disease that leads to insensitivity, get proper shoes. 1- LOPS, depth shoes and accomodative inserts. 2- LOPS and deformity, depth shoes, custom FO, rocker soles. 3- LOPS and Ulcer, healing sandal
Explain the gait activated stance control knees
Gait Activated Lock in full extension Biomechanical trigger to unlock Sensitive to gait variations
Finkelstein test
Game keeper, abductor pollicis brevis, extensor pollicis longus
Which muscles stop DF
Gastrocnemius/Soleus
Radial nerve injury, add
1st MP abduction assist
The second MP joint is abducted by
1st dorsal interosseus
A leg length discrepency over what length is enough to cause symptoms and require correction?
2 cm
The standard lateral inferior trimline for a single piece anterior opening custom LSO is:
2 cm or 3/4 inch superior to the greater trochanter
Describe adult HALO pin placement and torque.
2 pins anteriorly- 1 cm just superior to lateral 1/3 of eyebrow 2 posterior pins opposite anterior pins 8 inch-pounds of torque applied
The middle of the long finger has
2 volar interossei and a lumbrical
During Normal gait center of gravity shifts side to side ____
2"
Solid stirrup length is calculated by
2(Distal tip of malleolus to floor + sole thickness) + heel width + 6
What is normal ROM for Radial deviation
20 to 25 degrees (limited by styloid)
Normal ROM of ankle joint
20-30 of DF 30-50 of PF
Why a KAFO
Genu recurvatum >30*, Quad strength (<3+), coronal instability of knee, decrease knee pain
Which would you most expect to see in a patient with a plantarflexion contracture?
Genu recurvatum at midstance
Which pathology is most likely to be fit with free knee joints?
Genu varum deformity
Shoulder joint
Gleno-humeral joint
Motion occuring between carpal joints makes what type of joint
Gliding
Extensors of the hip
Gluteus Maximus, Semitendonosis, Biceps Femoris
Hip is flexed to what degree at IC
25 degrees
Mechanical hip joint in relation to the greater trochanter
25mm proximal, 12mm anterior
Lateral stability of pelvis in stance is accomplished through
Gluteus Medius
Inferior Gluteal Nerve
Gluteus maximus
Lateral stability of the pelvis in stance phase is accomplished through the action of which muscle?
Gluteus medius
What muscles does the musculocutaneous nerve (C5, C6, C7, C8, T1) innervate?
3 muscles of the anterior compartment of the arm: - coracobrachialis - brachialis - biceps brachii * provides sensory information from the skin of the lateral aspect of the forearm
How much DF is built into the scott-craig KAFO
3-5
Side bar clearance for conventional KAFO
3-6mm
What is average foot clearance during swing phase?
3/4cm
On a HALO how how much torque should be used on the superstructure?
30 inlbs
What is normal ROM for ulnar deviation?
30 to 35 degrees (limited by radial collateral ligament)
Normal fermoral anterversion
30-40 at birth 15-20 in adulthood males have less than females
Through Medical, heavy duty knee joints are only covered if the pt is above what weight?
300 lbs
What degree of knee flexion is required for ambulation
30º
Superior Gluteal Nerve
Gluteus medius Gluteus minimus tensor fasciae latae
forefoot eversion and inversion ROM
35 inversion and 15 eversion
Proximal clearances of a KAFO
35mm distal to perineum, 10mm distal to trochanter
Trendelenburg gait is caused by weakness of what muscle? and what nerve innervates
Gluteus medius and superior gluteal nerve
At what age does a child begin walking with heel strike at initial contact?
36 months
at what age does a child begin to walk with reciprocal arm swing?
36 months
Generally, a rear foot varus post should be no greater than what degree?
4 degrees
What percentage of gait is swing phase?
40%
A cycle of gait consists of
40% swing, 60% stance
You deliver a TLSO to a patient scheduled to discharge from the hospital in one week. The hospital states they cannot issue a purchase order because the device should be billed to Medicare. You should:
Inform the hospital that you cannot legally bill Medicare in this situation.
humeral extension muscles
lats teres major posterior delt infraspinatus teres minor triceps pec major
Where does the thumb post end on a rancho style hand orthosis
mid nail bed of the 1st digit
What are the normal accepted ROM for calcanea inversion and eversion?
5 and 5
During singe limb stance, what range of degrees PF/DF does the foot go through?
5 degrees PF to 10 degrees DF
Best wrist position for picking an object up from a table
5* Flexion
How can we use a conventional KAFO to address genu valgum (MCL/Lateral compartment)
5- Buckle Knee Pad • Wraps around lateral upright pulling laterally • 5 buckle pulls on the knee -allows for coronal plane adjustment • 4 buckle pushes on the segment Medial Knee pad • Mounted on medial upright pushes laterally
How can we use a conventional KAFO to address genu varum (LCL/Medial compartment)
5- Buckle Knee Pad • Wraps around medial upright pulling medially • 4 buckles allow for depth of the knee pad • 5th buckle goes around the structure and the upright to allow for varum/valgum control Lateral Knee pad • Mounted on lateral upright pushes medically
The muscle that has the PRIMARY responsibility of rotating the thumb to touch the tips of the index and middle fingers is the :
Opponens Pollicis
In standing, where is the weight distributed in a patient's feet?
50% on the heel and 50 through the MTPs
What is required to be a depth shoe?
Insert that is at least 3/16 inch thick, made from leather or similar, has closure, available in full and half sizes with at least 3 width option.
Legg-Perthes disease orthosis should hold hip joint in
Internal rotation and abduction
MP flexion and IP extension are performed by
Interossei and lumbricals
at what age is a baby able to sit
6 months
According to Medicare, diabetic shoes and inserts must be fit within how many months of original visit?
6 months, eval and delivery must be in person
How much should pins be torqued for a halo on an adult?
6-8 in pounds
KAFO w/ bilateral ring locks, what is the clearance
6mm medially, 3mm laterally
What percentage of gait is stance phase?
60%
what degree is knee flexion during swing phase
60-65 degrees during a normal gait cycle
Knee joint clearance
6mm medially, 3mm laterally
Clearance of ankle joints
6mm medially, 5mm laterally
Describe the function and features of the Gluteus maximus
It is innervated by the inferior gluteal nerve. It inserts on the gluteal tuberosity of the femur. Part of it originates on the ilium.
What is the maximum amount of knee flexion during swing phase?
70 degrees
What is normal ROM for wrist extension?
70-80 degrees (close packed)
Why is the musculocutaneous nerve rarely injured?
It lies deep to the biceps brachii, which offers protection
Nerve roots from the cervical
8
What is a stance flexion joint?
Load response joint ◦ Locks in full extension, then allows up to 15º of attenuated motion. -doesn't let knee buckle but allows a little give in knee during stance ◦ Fully extended in swing. ◦ Free when unlocked
On an adult HALO how much torque should be used on the pins?
8 in*lbs, 6 for older or osteoporotic
Adult halo torque
8 lb
During which phase of gait are the hip extensors most active?
Loading Response
scap retractors
middle traps rhomboid
What is normal ROM for wrist flexion?
85 degrees
Explain how the ankle activated stance control knee works
Locked in full extension Dorsiflexion to a specified degree unlocks joint Adequate ankle ROM is required
what age can a baby pull to stand
9 months
After providing a device to a Medicare beneficiary, the practitioner must provide any adjustments or repairs without charge for how long?
90 Days
What is the angle of DF/PF at heel strike?
90 degreed (0 DF and 0 PF)
Pavlik harness
90-100* Flexion of hip, 45* abduction
What does Pavlik harness maintain
90-100* Flexion of hip, 45* abduction
Damage to what nerve causes scapular winging?
Long Thoracic nerve
Which nerve impingement causes winging of the scapula?
Long thoracic nerve
What is Wolff's Law?
A bone grows or remodels in response to forces or demands placed upon it
When using a solid ankle AFO a smoother gait may be achieved with
A cushioned heel
Aponeurosis
A flat broad tendon
You see a patient post triple ankle arthrodesis. What is the best device to provide?
A rocker sole with SACH heel wedge
What is the primary benefit in using a spring over a rob in a double action ankle joint?
A spring does not affect stance phase stability
A C6 lesion would best be managed with
A wrist driven flexor hinge orthosis
S1 myotome
plantar flexion
in what position is the foot most unstable
plantar flexion and inversion
What anatomical deficit is related to a SCI with C5 escape?
Loss of all hand and finger function
When measuring for a quad brim which are the most important measurements
A/P, M/L
What is injured in an "Unhappy Triad Injury"?
ACL, MCL, and medial meniscus
Dorsal interossei do what
Abduct MP joint
A second MP abduction spring assist is used to
Abduct the second MP joint
Best position for chronically dislocating gleno-humeral joint
Abducted and externally rotated
To promote healing in a case of Legg Calve Perthes disease the hip should be positioned in:
Abduction and internal rotation
Serratus Anterior performs
Abduction and upward rotation
A metal single axis (free motion) orthotic hip controls
Abduction/Adduction, Internal/External rotation
On a HALO, do the headblocks go above or below the ring?
Above
Most prominent and highest point in the shoulder girdle
Acromion process
What is AROM?
Active Range of Motion -Patient actively moves through the range of motion of that joint
Which term describes the inability to generate FORCE when a muscle is in a fully shortened position?
Active insufficiency
Describe the tenodesis effect
Active wrist extension places tension on finger flexors, causing passive flexion of fingers.
While fitting a ground reaction AFO you observe good control of the patients knee in the agittel place however the patient complains they are having difficulty initiating swing on the side with the orthosis. The most appropriate modification would be :
Add a 1/4 inch heel wedge underneath the AFO
Your UCBL fits well, but your patient's foot is shifting medially in the orthosis. What modification do you make?
Add a medial post
At a follow up visit for a patient who was fit with bilateral solid ankle AFOs, you note redness at the navicular on the right side. What modifications should you make to the AFO?
Add an ST pad and padding just superior to the medial maleolus
Patient has a KAFO. Patient has a 15 degree PF contracture and 30 degrees of recurvatum. Patient is having a hard time getting over his foot at midstance. What mods to make
Add heel wedge may need contralateral heel lift
Volar interossei do what
Adduct MP joints
Symptoms of Erb's palsy
Adduction and internal rotation of humerus
Primary purpose of a C-bar
Adduction stop
Which muscles are innervated by the obturator nerve?
Adductor brevis Adductor longus Gracilis Not the Sartorius
Femoral or Scarpa's triangle
Adductor longus, Sartorius, Inguinal ligament
An orthosis for a burst fracture requires control in how many planes?
All 3, burst fractures are the most unstable.
What materials may we use with uprights
Aluminum - Square edge - Round edge Steel Titanium
ALS
Amyotrophic Lateral Sclerosis, DF assist light AFO, cervical support
UCBL contraindication
Ankle arthritis
At heel strike: ankle ____*, Knee ____*, Hip _____*
Ankle: 90* neutral, Knee: 180* Full Extension, Hip: 25* Flexion
What anatomical deficit is related to a SCI with C4 and above?
Loss of all upper extremity function
Which two types of orthoses are appropriate for compression fractures near the TL junction?
Jewett or CASH
The axis of rotation of the hip joint is located:
Anterior & superior to the greater trochanter
Anterior compression fracture of the spine involves which column(s)
Anterior Column
What double adjustable configuration should be used for a pt with Fair (2/5) plantar flexion strength, and good (4/5) dorsiflexion strength?
Anterior Pins and Posterior Springs
Describe a Dens 1 (anterior compression fracture)
Anterior column damaged only, flexion plus complession, posterior ligaments damaged
The proper placement length of the thumb post
Just beyond the nail bed
The most appropriate orthotic treatment for a patient with a T12 compression fracture is:
Anterior control hyperextension orthosis
T12 compression fx, what orthosis
Anterior control, hyperextension
Which structures are targeted when testing the knee for SAGITTAL plane stability? (2)
Anterior cruciate ligament (ACL) and Posterior cruciate ligament (PCL)
Spondylolisthesis is a condition best described as:
Anterior displacement of the L5 vertebra in relation to the sacrum
An orthosis for a patient post anterior cruciate ligament reconstruction should primarily control:
Anterior displacement of the tibia on the femur.
Where in the nervous system does Poliomyelitis affect?
Anterior horn cell
If the mechanical knee joint is too distal to anatomical knee axis
Anterior pressure is increased on the thigh w/ knee flexed
Define spondylolysthesis and describe treatment recommendation
Anterior slippage of superior vertebrae on inferior vertebrae Treatment: LSO with sagittal control
Spondylolisthesis
Anterior slipping of the superior vertebrae over the inferior vertebrae
A patient with hyperkyphosis is placed in a Milwaukee CTLSO for treatment. Where should the corrective pressures be placed?
Anterior throat ring, posterior thoracic pad
Where is the Center of Gravity located when standing erect?
Anterior to the edge of S2 vertebrae
The proper placement of the distal end of the thumb adduction stop (c bar)
Just proximal to the IP joint
The MP extension stop should be placed
Just proximal to the PIP joints
Distal edge of a C-bar should terminate
Just proximal to the pollicis IP Joint
what orthosis would you expect an L1 SCI patient to need
KAFO
What is the most appropriate way for a patient with unilateral weakness to ascend/descend stairs?
Ascend leading with the sound limb; descend leading with the affected limb.
A KAFO with a 90* DF ankle stop will
Assist in knee stability
A patient comes into the office exhibiting lasting redness on the navicular and medial malleolus after wearing her new AFO. What adjustment is most likely to correct this problem?
At a firm pad to increase pressure under the sustentaculum tali
DJD first affects the articular cartilage
Osteoarthritis
Spinal orthosis may have what effect on trunk muscles
Atrophy
Who are considered business associates under HIPAA regulations?
Attorney Accounting services Independent medical transcriptionist Not Courier
What is an adjustable extension knee joint
Available in drop lock or lever lock with 6º increments (also available with a 6-position flexion stop) No pneumatic aspect or assist, Not polycentric -if patient presented with full extension but the other side has flexion contracture at knee can adjust the knee joint at 6 degree increments as patients clinical presentation improves can just adjust lock angle
For a PTB orthosis, you must form material in popliteal area to
Avoid pressure on posterior tibial artery
A patient comes into your office stating low back pain caused by hyperlordosis. What advise might you give your patient to reduce symptoms?
Avoid wearing shoes with a heel higher than 3/8"
What tendon is damaged when mallet finger is present?
Avulsion of extensor digitorum tendon
Jefferson fx mechanism
Axial load to skull
What nerve is susceptible to injury during a fracture to the surgical neck or humeral dislocation?
Axillary - leading to loss of arm abduction past 15°, external rotation of the arm, and shoulder stability
Disadvantage of the round caliper shoe attachment
Axis is distal to anatomical
WHat would be the orthotic treatment and expected ambulation for an L1 complete spinal word injury?
KAFO (iliopsoas weakness). Household ambulation due to high energy costs
Can cause hip hiking
KAFO knee locked, short contralateral limb, knee ankylosing
If the patient does not have at least 3+ quads bilaterally and intact proprioception what orthosis would you eval for?
KAFo
Where is the thenar muscle
Base of the thumb
Which of the following is least likely to increase the likelihood of an infant developing a positional deformation of the cranium?
Below 50% on weight chart at 4 months of age
Heel wedge on a shoe for an AFO or KAFO should be where
Between the sole of the shoe and the stirrup
Superior surface of atlas articulates w/
Bicepital articularis
A lower motor neuron neuron injury to C6 affects what muscles?
Biceps and radial extensor
What is the function of the erector spinae when the act bilaterally? unilaterally?
Bilateral - extends the spine unilateral - laterally bend
What orthotic recommendation would you have for someone with a mallet finger?
Biomechanical need: Hold DIPJ in extension/ prevent flexion Goal: hyperextend and immobilize DIP to allow reinsertion Mallet cap
What orthosis would you recommend for a patient that has had a stroke which is now causing shoulder adduction spasticity and inferior subluxation of the shoulder joint?
Biomechanical need: Stabilization of the shoulder Goal: support the arm to prevent inferior subluxation Arm sling can be used to support the weight of the arm (eg Harris Hemi-sling)
What orthotic recommendation would you give someone with a swan neck deformity?
Biomechanical need: extension assist to DIPJ with flexion of the PIPJ Goal: 3PPS to prevent hyperextension at PIPJ and also allow flexion at PIPJ Swan neck splint - static
What orthotic recommendation would you have for someone with soft tissue injury at the elbow joint?
Biomechanical need: maintain elbow extension and prevent flexion - medio/lateral or hyperextension stability - prevent elbow flexion to stop undesirable action Goal: Apply 3PPS extension force to reduce flexion contracture post-trauma or surgery - stabilize elbow joint - control ROM at the elbow joint Dynamic elbow orthosis - apply extension assist or stretch Static elbow orthosis - maintain position, support protect Hinged elbow orthosis - M/L and hyperextension support
What orthotic recommendation would you have for someone with DeQuervain's Tenosynovitis?
Biomechanical need: prevent excursion of EPB and AbPL tendons - stabilize the thumb and wrist in neautral position as these long tendons cross the wrist joint Static long opponens orthosis (WHO with thumb post)
Causes of genu valgum
Blounts, Rickets, Idiopathic
What is the lubricant filled sac which, if removed, results in increased friction?
Bursa
Legg-Calve-Perthes disease
Osteochondritis of the capital femoral epiphysis, goal contain femoral head in acetabulum
Component for hand lacking thumb abductor strength
C bar
What anatomical deficit is related to a SCI with C7 escape?
Loss of finger flexion and extension (but maintains ext. carpi radialis L&B and ext. carpi ulnaris
In a metal AFO how do you accommodate tibial torsion
Deflections of stirrup extensions
What anatomical deficit is related to a SCI with C8 escape?
Loss of opposition and intrinsic hand muscle function
What roots contribute to the dorsal scapular nerve?
C5
what roots contribute to the dorsal scapular nerve?
C5
Which level of nerves does the axillary nerve carry?
C5 and C6
what roots contribute to the long thoracic nerve?
C5, C6, C7
What spinal segments are involved in the brachial plexus?
C5, C6, C7, C8, T1
What roots contribute to the long thoracic nerve?
C5, C6, and C7
Brachial plexus nerve roots
C5-T1
What nerve roots does Klumpkes palsy affect?
C8 T1
Examples of upper motor neuron lesions
CP, frederiches ataxia, spinal cord trauma, tumors Upper lesions are not progressive
Orthoses to treat Scheurerman's
CTLSO (Milwaukee)
Orthotic treatment for a T3 fx
CTLSO (Taylor - CO)
A T1 level fx will have 3-point with what orthosis
CTO
KAFO causing flexion, why
Calf band is too shallow, needs to be deepened
Describe Torticollis
Can be caused by tightness of the sternoclaidomastois, tumors, infections, and more. Head tipped toward shoulder, rotated on longitudinal axis,
Solid ankle AFO - contraindications
Can impede balance marginal success with athetosis or ataxia impedes 1st, 2nd, and 3rd rocker, making for stiff gait and shortened stride length
Inflammation anterior to the flexor retinaculum
Carpal tunnel
What are the most common forms of median nerve injury?
Carpal tunnel syndrome
What is the primary target organ in rheumatoid arthritis?
Cartilage
During the casting of an ambulatory child with CP for custom bilateral solid ankle AFOs you note that the right side lacks dorsiflexion range of motion (-5 degrees) with the knee extended. The MOST appropriate way to address this is:
Cast in -5 degrees of dorsiflexion and plan to add an external heel wedge.
Which does not cause spasticity
Cauda equina
Describe Periarthritis humeroscapularis
Degenerative transformations at the tendon insertion of the shoulder joint, caused by trauma, overloading, or irritation of the cervical nerve roots, ROM limited, Orthosis: Immobilization with abduction.
Describe adhesive capsulitis?
Characterised by restriction in shoulder motion in external rotation, abduction and flexion, inflammation and fibrosis of the shoulder
What should you check in regards to the ankle joint during fitting? What are the clearances?
Check for ankle joint alignment? • Frontal - axis should be perpendicular to mid-sagittal line. • Sagittal - axis should be located at the midpoint of the distal tip of the medial malleolus. Clearance: • 5 mm lateral side • 6 mm medial side
What should you check in regards to the knee joint during fitting? What are the clearances?
Check for proper knee joint alignment • Frontal - axis should be perpendicular to Mid-Sagittal line. • Sagittal/Transverse - Centered on the anatomical joint center. Clearance: • 3mm lateral • 6mm medial
What are measurements when measuring for a custom TLSO?
Circumferences: chest, xyphoid, waist, asis, trochanter or 1 inch below, and breast circum MLs: chest, Xyphoid, waist, asis, and 1 inch below troch Length: everything to waist sternal notch, nip line, xyphoid, superior spine of scap, inferior scap, and axilla asis, pubic symphysis, trochanter, coccyx, gluteal fold
What are the differences between "claw" hand and the sign of Benediction?
Claw hand- ulnar nerve - permanent position of the hand at rest Sign of Benediction- median nerve - active attempt to flex digits
An involuntary oscillating movement elicited by a rapid stretch is:
Clonus
closed vs open fracture
Closed = skin intact Open = bone protudes through skin
How are you supposed to code?
Coding decisions should accurately reflect appropriately provided services
Describe Clubfoot presentation (5)
Combination of: -Supination -Forefoot adduction -Ankle equinus (inadequate DF ROM) -Calcaneal varus -Medial deviation of foot in relation to knee
Paralytic equinus is caused by injury to what
Common peroneal nerve
complete vs incomplete fracture
Complete = fracture goes through both cortices of bone Incomplete = does not go through entire bone
What is an ASIA level A?
Complete. No motor or sensory below the level
Principle of orthotic fracture casting (tibia)
Compression - middle 1/3 (femur only distal 1/3), 10* varus/valgus, 20* A/P angulation
Describe a Dens 2 (Burst) fracture
Compression plus flexion, anterior and middle columns damaged
A Volkmann's ischemic contracture is caused by
Compromised vascular flow
In Scoliosis, the spinous process deviates towards which side of the curve?
ConCavity
Describe Arthrosis
Degenerative, associated with wear and team, pain, loss of ROM, muscle weakness, progressive, orthotic treatment to relieve pressure and slow down progression
What the the required to be a custom-molded shoe?
Constructed over positive modal of pts foot, made from leather or similar, has removable inserts, has closure
Patient wearing a Dennis Brown orthosis has eversion, what do you do
Contour the crossmember concave to the pt to supinate foot
What is the most common symptom of ACA (Anterior cerebral Artery) syndrome?
Contralateral hemiparesis and hemisensory loss of the lower extremity
What is the release mechanism for a gait activated stance control knee
Control what is happening in stance phase Locks as you put weight into it during stance; when it hits a specific triggor point it unlocks and allows the knee to flex during swing phase The lock is reingaged when weight is put into it again weight sensors in the foot plate when the heel senses weight the knee locks as the toe senses weight it unlocks the knee
In scoliosis, the vertebral body is distorted toward which side of the curve?
Convexity
Which plastic is best used when some flexibility is required?
Copolymer
At what section of the brachial plexus are the nerve route bundles classified based on their orientation with the axillary artery?
Cords * lateral, posterior, and medial
Floor reaction AFO contraindications
Coronal instability of knee, genu recurvatum
Abduction and Adduction occur at which plane
Coronal plane
Adduction and Abduction occur in ____ plane(s)
Coronal plane
C5-c8 injury to the brachial plexus
Klumpke's Palsy
Lesion to femoral nerve at lumbar plexus affects
Knee extension
Control differences of knight taylor TLSO vs Taylor
Knight taylor = A/P and ML Taylor = A/P
Extension of the proximal phalanx at the MP joint is produced by
Extensor Digitorum Longus and Interossei
What muscle closely duplicates the function of the tibialis anterior?
Extensor Hallicus Longus.
What muscle is similar in function to the tibialis anterior
Extensor Hallucis Longus
In Scoliosis, the rib hump is on which side of the curve?
Covexity
Axial alignment in newborns
Coxa valga internal rotation (30 degrees) genu varum bow legged dorsi flexion (45 degrees)
Strength of a muscle is determined by
Cross section of the muscle
In a double action ankle joint, what are the two anterior channel deficits?
Crouching, knee instability
Name the three radial deviator muscles
Extensor carpi radialis brevis, extensor carpi radialis longus, flexor carpi radialis (all of the radial ones)
C6 quad uses which muscles for wrist driven orthosis
Extensor carpi radialis longus and brevis
Name the Unlar deviator muscles
Extensor carpi ulnaris, flexor carpi ulnaris
Extension at the MP joint is produces by what muscle
Extensor digitorum
Which muscle closely simulates anterior tibialis
Extensor hallucis longus
At what level does the spinal cord end?
L1 (conus medullaris) Injuries below this are to peripheral nerves.
Some recovery can be expected in complete spinal cord injuries below what level?
L1 and below, the spinal cord ends at L1
Where are the iliac crest rolls on a boston brace?
L2-L3 disc space
what level are the iliac crest rolls at on scoli brace
L2-L3 disk space`
In which of the following conditions is a Milwaukee CTLSO contraindicated? a. Skeletal immaturity, b. idiopathic scoliosis, c. thoracolumbar curves, d. curves greater than 60 degrees
D. Curves greater than 60 degrees
Pt w/ paralysis of PF needs which ankle joint controls
DF stop
When a bilateral KAFO patient leans into his iliofemoral ligament the tibias should be
DF to accommodate
Excessive circumduction may result from weakness in
DF, Hip flexor
Function - Tibialis Anterior
DF, Inversion
Describe Gonarthrosis and the appropriate orthosis
Damage to the cartilage of the knee joint. Typically widening of the knee area and decrease of active flexion. Typically an offloaded is used to slow progression
LLE Anterior compartment
Deep Peroneal Nerve - Tibialis Anterior, Extensor Digitorum Longus, Extensor Hallucis Longus
A patient wearing a metal and leather KAFO with double adjustable ankles experiences excessive knee flexion during standing. To reduce this the orthotist should:
Deepen the calf band.
What deficit causes foot slap?
Deficit of dorsiflexors working eccentrically
A patient presents with excessive tibial torsion. How should this be incorporated into a conventional double upright AFO?
Deflect the sidebars
How do you accommodate tibial torsion
Deflect uprights
Muscle that can flex, abduct, extend and support the shoulder
Deltoid
A lower motor neuron neuron injury to C5 affects what muscles?
Deltoid and biceps brachii
Explain Dens 1-4
Dens 1 - anterior compression fx Dens 2- burst fx Dens 3- Chance Fx Dens 4 - dislocation
Zig-zag deformity
Destruction of joint space caused by OA/RA= painful ROM - radial deviation of wrist with ulnar deviation of fingers
When treating a patient with a knee flexion contracture, what is the most appropriate knee joint to use when designing a KAFO?
Dial Lock Joint
Describe purpose of UCBL
Diminish calcaneous ML instability
What determines the location of the trochanter pad on a scoliosis orthosis?
Direction of L5 tilt
A patient with positional plagiocephaly has been wearing a custom cranial remolding orthosis for the past 8 months. The patient is not 15 months old and has outgornw the orthosis. The practitioner should expect the physician will:
Discontinue orthotic treatment since the childs head growth has plateaued.
Patient is in your office for a scoliosis TLSO adjustment. You note the orthosis is too small and her latest x-ray shows a Risser sign of 4. What action should you take?
Discuss weaning out of the orthosis and refer patient to physician for end of treatment
Charcot joint results from
Disruption of the sensory pathways
Humeral fx can be managed if
Distal 2/3
When fabricating a thermoplastic articulated AFO, the mechanical ankle joints should be placed at the level of the:
Distal border of the medial maleolus
Wrist joint placement
Distal radial styloid
What is a Colle's fx
Distal radius
What is the location of the mechanical axis of the ankle joint?
Distal tip of the medial malleolus
When aligning a bail of a CAM lock knee, which way should posterior aspect be angled
Distally
At what section of the brachial plexus do the nerves form into flexor (anterior), and extensor (posterior) compartments?
Divisions
What are some signs of the radial nerve palsy?
Extensor muscle paralysis - "wrist drop" - inability to extend thumb, prox. phalanges, wrist and elbow Position of hand: - pronated - wrist and fingers flexed - adducted thumb - inability to make a fist or grasp - triceps, radial and periosteal-radial reflexes are absent - loss of sensory feedback from dorsal radial surface of the hand
While the patient is sitting what are some additional observations that should be made in regard to orthosis fit
Does the shoe fit appropriately? Can the patient efficiently don and doff the orthosis without any assistance? Does the orthosis fit properly without causing excessive pressure? Adequate clearance of soft tissue(ex: popiteal fossa)
When treating an anterior hip dislocation
Don't allow hip to extend past 30* of flexion
The sensory distribution of the spinal nerves is
Dorsal
Which muscle serves to abduct the phalanges away from the 3rd digit?
Dorsal Interossei
Sensation is transmitted through
Dorsal branch of nerve root
Where are the wrist extensors
Dorsal forearm
In what position is the ankle joint most stable?
Dorsiflexion
The trim lines of a ground reaction AFO should be anterior to the malleoli to serve as a :
Dorsiflexion Stop
How would you configure your double action ankle joints to provide swing phase clearance and to minimize foot slap at initial contact?
Dorsiflexion assist - Spring posterior, free anterior
What muscles are specifically active during weight acceptancE?
Dorsilexors(eccentrically) Restraining knee flexion: Soleus and posterior tibialis, quadriceps, hip extensons semitendinosis, biceps, and gluteus max
How do you find decomposition on an XRAY
Draw a centerline through S1 and which side is the head on. Usually the same as L5 tilt
Extends distal phalanx of thumb
Extensor pollicis longus
In general terms the radial nerve innervates ___
Extensors and supinators
What orthotic recommendation would you give someone with a boutonniere deformity?
Dynamic (with spring wire) or static Boutonniere splint (eg. Digisplint)
What orthosis may you recommend for someone with combined median and ulnar nerve palsy (intrinsic minus hand)?
Dynamic positioning of the thumb, and 4 MCPJs to encourage joint mobility and augment hand function Static positioning of thumb and fingers to prevent contractures
What orthosis would you recommend for someone with ulnar nerve palsy resulting in "claw hand"?
Dynamic ulnar nerve palsy orthoses (eg. spring wire) to encourage joint mobility and augment hand function static orthoses for positioning and prevention of contractures
Contraindication for spiral AFO
Edema, volume changes
The primary function of the brachioradialis is:
Elbow Flexion
With tennis elbow you want to eleviate what
Elbow extensors
Biceps function
Elbow flexion, forearm supination
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):
Elevation of the 2nd-5th MTP joints and digits. - help decrease tone 1/4" heel/lateral wedge. - negate the post-lat thrust PF stop. - stop drop foot and knee hyperextension Metatarsal pad. - help decrease tone
What condition is often the result of an irregular birth?
Erb's Palsay
What is the prime extensor of the vertebral column?
Erector Spinae
Muscles for spinal extension
Erector spinae, Quadratus Lumborum, Levator Scapulae, Latisimus Dorsi
If a KAFO has insufficient external rotation, then ___ will occur
Eversion
Motion lost w/ the loss of the superficial common peroneal nerve
Eversion
Superficial branch of the common peroneal nerve
Eversion
Pronation
Eversion, Abduction, DF
Langenskoild staging
Ex. Varus deformity will increase with prolonged pressure
Best way to accommodate valgus in a pt's lower limb
Extend the medial stirrup extension
A lower motor neuron injury causes what type of paralysis?
Flaccid
Lower motor neuron injury
Flaccid or hypotonic response
What are some characteristics of a lower motor neuron injury?
Flaccid, decreased tone, degreased stretch reflexes, profound muscle atrophy, fasticulations present, sensory disturbances.
Lumbricals function
Flex MP joints, Extend IP joints
First dorsal interosseous muscle do what to the 2nd MP joint
Flex and abduct
Brachioradialis function
Flex elbow
The lumbricals function to:
Flex the MCP joints and extend the PIP joints
When casting for a milwaukee CTLSO, the pelvis should be
Flexed
What position is the hip at during heel strike?
Flexed 30 Degrees
A patient w/ weak quadriceps using a floor reaction will walk with
Flexed knee gait
Hip position for highest risk of dislocation
Flexed, internal rotation, adducted (MVA)
Position of thoracic articular facets are most disadvantageously positioned to allow
Flexion
Swan neck deformity refers to which position?
Flexion of the DIP joint, hyperextension of the PIP joint
Flexor of hand not supplies by the median nerve
Flexor Carpi Ulnaris
Which muscle remains functional in a quadriplegic pt w/ lesion below the C6 root
Flexor Carpi Ulnaris
What muscles flex the wrist? Where do they originate?
Flexor Carpi radialis (median nerve, C6-C7), flexor carpi ulnaris (Ulnar nerve, C8-T1). Originate at medial epicondyle
Flexion of distal IP joints (muscle)
Flexor Digitorum Profundus
Muscle acting primarily on the PIP joint
Flexor Digitorum Superficialis
A lower motor neuron neuron injury to C8 affects what muscles?
Flexor digitorum superficialis, flexor digitorum profundis, lumbrcles
Muscle around thumb that does not abduct it
Flexor pollicis brevis
Medial epicondyle of humerus is origin of the
Flexors
A peripheral nerve injury of the peroneal nerve would cause
Foot drop and Inversion
In a double action ankle joint, what are the two posterior channel deficits?
Foot drop and hyperextension
Peroneus Longus does what motion to the foot
Foot eversion, ankle PF
What is the importance of good documentation?
For accountability, professional conduct, or justification for approval
What orthosis would you recommend for someone with carpal tunnel syndrome that has resulted in muscle weakness?
Goal: stabilize the wrist in a neutral position for rest and functional use - prevent tension or compression of the median nerve Static wrist hand orthosis (WHO) - plastic or leather design
What orthosis would you recommend for someone with median nerve palsy that has resulted in loss of the opposition to the thumb?
Goal: static or dynamic positioning of the thumb for function Biomechanical need: MPJ flexion, CMCJ abduction, CMCJ pronation Static thumb post or dynamic thumb positioning with elastic components
Median nerve palsy orthosis
HO opponens orthosis
With a median nerve injury at the wrist
HO w/ thumb post
What kind of brace would you use for an unstable ondontoid fracture?
Halo is indicated for unstable C1 and C2 fractures
Ape hand is another name for what presentation?
Hand of benediction
Gower's sign is best described by which of the following?
Have the patient move from a seated position on the floor to standing. The patient using his or her arms to walk up the thighs is a positive sign.
What's the best way to eliminate pressure at the proximal posterior of the AFO worn to control mild genu recurvatum?
Heat and flare the proximal trimline
Heel lever arm tends to force knee into flexion at
Heel contact
Maximum DF occurs during
Heel off
Most active muscles in gait, when
Heel strike
Most hip flexion during gait
Heel strike (30*)
A single gait cycle is termed as the activity that occurs from
Heel strike on one side to heel strike on the ipsilateral side.
When does stance phase begin and end?
Heel strike to toe off
Bunnell (cock-up) splints are used for
Hemiplegia
The congenital abnormality of the spine in which one side of the vertebra is incompletely developed is:
Hemivertebra
What are the L codes for double uprights? What is the difference between them
L2020 or L2030 2030 does not have knee component; good for patient with fused knee -Base code is for solid stirup (if you want split it would be an add-on)
The Coleman lateral block tests
Hindfoot varus
What are the actions of the Sartorius
Hip Flexion External Rotation Knee Flexion
Describe Coxarthrosis
Hip deformity causing dislocation of the femoral head out of the acetabulum. Primary is congenital, secondary is is adulthood.
Patient with muscular dystrophy walks with increased lumbar lordosis secondary to which muscular weakness?
Hip extensors
The patient is experiencing recurrent positional posterior dislocation after hip replacement surgery. The Primary goal of a hip abduction orthosis is to block what?
Hip flexion
What is the Thomas test for?
Hip flexor tightness
What are some examples of stance control knees
Horton UTX and Free Walk E-Knee SPL Sensor Walk Stride C-brace
What is the primary orthotic goal for Dens fractures
Hyperextension
Swan Neck
Hyperextension of the PIP and hyperflexion of the DIP
What does the Ober Test assess for?
IT band tightness or hip extensor tightness
In what case would bilateral trochanter extensions be used?
If L5 tilt and decomposition are on opposite sides
Lateral flexion radiographs for scoliosis determine
If curve is flexible
What are some considerations to make when providing KAFOs for coronal plane deformities
If its rigid not doing a KAFO if it is correctable make sure they can handle the correctable alignment
A dynamic IP extension assist w/ an MP stop should be used
If pt is unable to extend fingers at both MP and IP joints
Prevents excessive hip hyperextension
Iliofemoral ligament
Which ligament prevents hyperextension of the hip joint?
Iliofemoral ligament
What is the Y ligament?
Iliofemoral ligament. extends from the ilium to the femur
Major flexor muscle of hip
Iliopsoas
Primary flexor of hip
Iliopsoas
The primary hip flexor is the:
Iliopsoas
What is the ober test for?
Iliotibial band tightness
Supination
Inversion, Adduction, PF
Does a single upright lock?
In general if using unilateral joint not meant to lock would be much thicker if you want locking feature
What is asia D?
Incomplete motor function preserved below the level. But half the muscles are a grade 3 or more
What is an asia B?
Incomplete sensory but no motor function
Biomechanical principle for unloading an intervertebral disc
Increased intrabdominal pressure
What is athetosis?
Involuntary slow, irregular twisting motions of limbs, fingers & hands. Usually affects the upper body more than lower
Scheurerman's kyphosis is characterized by
Irregular/wedge shaped vertebrae
Describe Arthritis
Inflammatory, affects joints, muscles, tendons, and ligaments, redness, swelling, heat, Orthosis typically not indicated.
Patient w/ an inferior myelomeningocele may develop a hip flexion contracture due to
Lack of hip extensors to anatgonize, parental non-compliance w/ home stretching
A patient was fit with a pair of custom semi-rigid orthoses two weeks ago. They are now complaining of discomfort on the plantar aspect of their feet, just proximal to the 1st met heads. The MOST likely cause of this problem is what?
Lack of relief for the flexor hallicus longus tendon.
End point vertebrae in a scoliotic curve
Last convergent vertebrae most superior and inferior to null point
HALO pin placement
Lateral 1/3 of eyebrow
Flexible varus hindfoot can be corrected using
Lateral heel wedge
Hip Flexion ROM starting position, degrees, and motion
Laying in Supine, 120-130. bend hip up towards chest
A patient presents to your office with bossing of the right posterior cranium and flattening on the left posterior cranium. How would you classify this?
Left posterior brachycephalic
What type of curves are signs of neuromuscular scoliosis
Left thoracic right lumbar
Osteochondrosis of femoral epiphysis
Legg-calve-perthes, 3-10 y/o males most common
Metal AFO, fixed varus at subtalar can be accomodated by
Lengthen lateral stirrup
A plantarflexion stop is helpful in controlling genu-recurvatum of what degree?
Less than 20 degrees recurvatum
What is the windlass effect?
Lifting of the longitudinal arch due to the hyperextension of the MTP's Hyper extend the toes, pronate the foot, hindfoot varus, externally rotate the tibia
Toe out/Toe in is in relationship to what
Line of progression
Poliomyelitis is what type of pathology?
Lower motor neuron
Flaccid paralysis is most often seen in:
Lower motor neuron injuries
The measurement for a TLSO ( anterior hyperextension orthosis) should be taken with the patient in what position?
Lying Supine
Extension fo the wrist causes
MCP Flexion
plantar fascitis treatment
ML arch support cushion heel
rx for pes equinus
ML arch support low heel
Intrinsic muscles of the hand do what to MPJ and IPS
MP - Flexion, IP - Extensor
The orthotic recommendation for treating a patient with an ulnar nerve lesion at the wrist is an opponens orthosis plus what component?
MP stop
Upper motor neuron disorders
MS, CP, CVA
Upper motor neuron injuries
MS, CP, SCI, CVA
What are the components/structure of the weight bearing KAFO
MUST have solid ankle and double upright locking knee. -reason: reliability for patient and patient safety Quad brim -Good for muscular patients -(variant - ischial ring) Ischial containment - Improved comfort/control of fleshy limbs
Describe slipped capital femoral epiphysis
Males> Females, age onset 13 years, AROM restricted in abduction, flexion, and internal rotation, vague pain at him, knee, and thigh
Describe Legg-Calve-Perthesis disease (osteocchondrosis)
Males>females, average onset age 6 years old, psoatic limp due to major weakness, lower extremity moves into external rotation, flexion adduction, MRI will show collapse of subchondral bone at femoral neck
How do we manage for knee buckling orthotically
Managed in THREE ways above the knee - Manually locking knee joint (like drop-lock) - Posterior offset joint - Stance control knee joint
Clavicle and sternum articulate at
Manubrium
Why do we use internal uprights?
Material strength adds to upright strength thermoplastic and resin put over upright increaded height = increased stiffness imporves coronal plane control
Which structures are targeted when testing the knee for CORONAL plane stability?
Medial Colateral Ligament (MCL) and Lateral Colateral Ligament (LCL)
Carpal Tunnel Syndrome results from the compression of what nerve?
Median
Ape hand is a lesion of what nerve
Median nerve
What nerve innervates opponens pollicis
Median nerve
What nerve is damaged when an "Ape hand" is presented?
Median nerve
What nerve is damaged when the sign of Benediction is present?
Median nerve
Congenital osteoperosis, fractures before and during birth are signs of
Osteogenesis Imperfecta
Supination of the ankle is comprised of what motions?
plantar flexion, varum, and forefoot inversion
Inflammation of the outer covering of the brain and spinal cord describes what condition?
Meningitis
Inflammation about the SCI and brain is
Menningitis
MUD
Metacarpal ulnar deviation * RA deformity
Abduction and Adduction occur at what joint in the hands
Metacarpal-phalangeal joint
Adductors of the scapula
Middle trapezius, Rhomboids, Latissimus Dorsi
Which phase is M/L stability most important
Midstance
Which phase of gait does a rocker sole simulate
Midstance to toe off
Where is the mechanical KNEE joint access located?
Midway between adductor tubercle and medial tibial plateau
Pelvic band placement
Midway between iliac creast and greater trochanter
A ___ orthosis is often used to treat kyphosis
Milwaukee
Soft cervical collar's are most effective for
Minimize forward flexion
Which curve of a double spinal curve is more flexible?
Minor curve
pes cavus rx
Ml arch support met pad high toe box for claw toes
After casting a post polio patient you notice the patient has valgum
Modify to correct: remove plaster from your counter points - Lateral thigh, medial knee, lateral fibula
What is the clonus reflex?
Monosynaptic uninhibited reflex arc quick dorsi flexion and the foot beats up and down
More clearance for medial malleolus, why
More prominent
What area of the body does the brachial plexus provide innervation for?
Motion innervation: - arm - forearm - shoulder - hand Sensory innervation: - bones - skin - muscle - connective tissue * to the shoulder and upper extremity
What areas of the body does the brachial plexus provide innervation for?
Motion innervation: - arm - forearm - shoulder - hand Sensory innervation: - bones - skin - muscle - connective tissue * to the shoulder and upper extremity
Describe chaeroarthropathy
Motor neuropathy in upper extremity, cannot touch pamls together in prayer position, atrophy of webspace, limited joint mobility (cannot place hands flat on table)
Difference between muscle spasm and spasticity?
Muscle spasm is localize muscle contraction because the brain signals the muscle to contract Spasticity is when nerves in the spine cause the muscles to control. The brain no longer communicates with the motor nerves
Innervates all muscles of anterior arm
Musculocutaneous nerve
What orthotic recommendation would you give someone with a SCI with C4 and above involvement?
Power driven mobile arm support with power drive flexor hinge hand
Maximum plantarflexion occurs at what phase of gait?
Pre Swing
GRAFO trimlines
Proximal: just inferior to tibial tubercle ankle: anterior to ankle with anterior opening from foot plate to just high enough to allow foot to pass through posterior: beginning just able calcaneal tuberocity and extending upwars only enough to allow foot to pass through full foot plate
Medial compartment syndrome means
Needs a lateral force directed medially to fix
Duchenne Muscular Dystrophy
Neuromuscular disease, Gower's sign (walk with hands up quads to standing position-quad weakness)
Contrainidications for an RGO (Recipricating Gait Orthosis)
No family support, poor upper body strength, obesity (*RGO's help with contractures in hip)
Explain how the weight activated stance control knee works from IC through preswing
No weight, the knee is free moving when you hit IC it is still not locked; once loading response begins their is weight in the joint and the knee locks When you get to pre-swing and weight shifts to the uninvolved side the knee unlocks
Is CP progressive?
No, but deformities and contractures may develop due to bone growth and other factors
Which type of scoliosis is most likely the result of a leg length discrepancy?
Non-structural Scoliosis
What is Asia E?
Normal Motor and sensory functions are normal
The gelatinous center of a spinal disc is the:
Nucleus Pulposus
The superior articulating surfaces of the atlas articulate w/
Occipital condyles
The rules relating to the safe use of potentially hazardous materials in the fabrication of orthoses are under the jurisdiction of what organization?
Occupational Safety and Health Administration (OSHA)
A patient who has relocated to your area comes in with a device fabricated at another orthotics and prosthetics facility. The patient is in our office because of discomfort and dissatisfaction with the overall fit. Upon evaluation you notice some minor fitting problems but the main problem is that the assembly of the device is structurally unsound. What should you do?
Offer to provide immediate structural repais
What is a hybrid KAFO? What is the benefit to a thermoplastic distal section? conventional?
Often combines the best features of both systems. Thermoplastic distal section may control foot/ankle while leather top increases sitting comfort. Conventional distal section may accommodate edema while thermoplastic thigh provides more control.
Patient has abrupt knee flexion at loading response with an articulating afo with a PF stop. What could be the issue
PF stop to Dorsi flexed firm heel wedge on the bottom
Supination
PF, Inversion, Adduction
A boutonniere deformity consists of :
PIP flexion and DIP hyperextension
Describe a boutoniere deformity
PIP flexion, DIP hyperextension, inferior sublaxation of lateral bands of extensor tendon
Swan neck deformity consists of:
PIP hyper-extension and DIP flexion
Describe a Swan Neck Deformity
PIP hyperextension and DIP flexion. Superior sublaxation of lateral bands of long extansor tendon.
What materials are used for thermoplastic KAFOs
PP, Co-poly, HDPE, lamination
Anatomical hip joint in relation to greater trochanter
Proximal and anterior
Duputryen's contracture involves
Palmar aponeurosis (Robert, Sign Language 3)
A HO controls
Palmar arch and thumb position
A hand orthosis controls:
Palmar arch and thumb position
A lower motor neuron neuron injury to T1 affects what muscles?
Palmar interossei, dorsal interossei
Positive Trendelenburg sign is an indication of
Paralysis of hip abductors
Spinal cord injury at T2-T3 results in
Paraplegia w/ spasticity
A young child with a T12 myelomeningocele is seen in your office for a device that will help patient ambulate in the home and classroom and will allow hands free standing. What device do you evaluate him for?
Parapodium
Posterior uprights on a lumbosacral orthosis should be where
Paraspinal muscles
What is PROM?
Passive Range of Motion -Therapist stabilizes proximal joint segments and moves distal segment(s) through full ROM
What occurs when the length of a muscle prevents full ROM at the joint or joints the muscle crosses over?
Passive insufficiency
Hip extension ROM starting position, degrees, and motion
Patient in prone, extend hip up to the cieling, 10-15 degrees.
How to perform a thomas test
Patient is lying in supine. Flex one knee up to the chest and have the patient hold it there. If the other leg which is laying on the rises up then that is indicative of a contracture on that side.
What's the best way to test the difference between grade 3 and grade 4 psoas major strength?
Patient lies supine with knee extended; examiner resists hip flexion.
What muscles are specifically active during single limb balance?
Pelvis stabilization by hip abductors: gluteus medius, gluteus minimus, tensor fascia femoris Restraint from medial knee muscles (resist valgus): vastus medialis, semitendinosis, gracillis Restraint by posterior tibialis and medial insertion of soleus
When taking plaster bandage impressions for upper limb, the second MP joint should be ___ in relation to the first
Posterior
What pin/spring configuration would you use for planterflexion spasticity?
Posterior Rod
Describe a Dens 3 Chance Fracture
Posterior and middle column damaged to vertebral body, Flexion plus disarticulation (seat belt injury)
What pin/spring configuration would you use for foot drop without spactivity?
Posterior spring
A patient reports pain at the navicular and posterior to the medial malleolus. What is the most likely pathology?
Posterior tibial tendon dysfunction
Flaccid paralysis is most often seen in
Peripheral nervous system injuries
Sacral Plexus
Piriformis superior gemelli inferior gemelli obturator internus quadratus femoris
During quiet standing, what muscles are acting on the ankle in the sagittal plane
Plantar Flexors
The functions of the tibialis posterior muscle are:
Plantar flexion and inversion
What are some examples of a lower motor neuron injury of and anterior (ventral) horn cell?
Polio, spinal muscular atrophy
Examples of lower motor neuron lesions
Polio, spinal muscular atrophy, traumatic These are progressive
What is the best plastic for upper extremity and spinal orthoses when more flexibility is required?
Polyethylene
Which plastic is best used when rigidity is required?
Polypropylene
Pure sensory nerve
Popliteal Nerve
Purpose of the thumb post
Positioning for palmar prehension
The main reason for a WHO, instead of an HO is
Positioning the wrist
Which muscle inserts on the navicular and medial cuneiform?
Posterior tibialis
Weight line at initial contact
Posterior to ankle and knee, anterior to hip
Describe the trim lines on a TLSO
Posterior: Sacrocrococcygeal joint to scapular spine. Anterior: symphysis pubis to sternal notch
For Medicare: what thickness and shore combinations are acceptable as a prefab base layer vs a custom base layer?
Prefab: 1/4 inch of shore 35 A or higher, 3/16 inch of shore A 40 or higher Custom: at least 3/16 inch of 35 Shore A or higher
Why is a Milwaukee brace molded superior to iliac crest
Prevent distal migration
Good purchase on the pelvis is required in spinal orthotics to
Prevent motion at lumbosacral junction
Purpose of illiac crest roll on a boston brace?
Prevents distal or proximal migration of the brace and aids in positioning the pelvis in posterior tilt
Quadriceps Femoris
Primary extensor of knee, Inserts into the tibial tuberosity, 4 parts (1 across the hip)
Pronator quadratus
Pronates forearm
How does an orthosis substitute for ligaments?
Protects the joint against excessive translatory movement
The main functional goal of a posterior off-set unlocked knee joint is to:
Provide increased stability during stance (this is a better answer than to prevent buckling at initial contact)
Primary function of GRAFO
Provide plantarflexion knee extension couple resists knee buckling improves energy efficiency in gait
You deliver a device in the hospital to a patient who is not able to communicate. You should:
Provide the nurse with verbal instructions and leave written instructions
What must be included on a Detailed Written Order?
Pts name, diagnosis, detailed discription of item, physician signature, and date entered by physician. (and order start date if already dispensed)
Hip max extension during
Push off
What ankle action provides shock absorption at loading response?
Quick Plantarflexion
Which nerve innervated the wrist extensors, what are the muscles? Where do they originate?
Radial Nerve (C6-C8), extansor carpi radial brevis, extensor carpi radialis longus, extensor capri ulnaris ** origionate on the lateral epicondyle
What is the most commonly injured peripheral nerve?
Radial nerve
What nerve is affected with "Saturday night" or "honeymooners" palsy?
Radial nerve
Facilities material safety data sheets should be:
Read by all staff that uses the materials
WHat hormone is released in pregnant women that increases the elasticity of connective tissue to assist in birth? What orthosis can help?
Relaxin hormone, SI belt
Two functions of metatarsal pads
Relieve met heads, elevate transverse arch
Before the patient leaves after you've checked gait, alignment, etc. what do you need to check
Remove the orthosis and check for any areas where corrective forces are being applied to make sure that there isn't any unusual redness/irritation. If significant redness is noticed over an area where a bony prominence is contacting the orthosis, you would want to relieve pressure to improve comfort without losing stability.
Erb- Duchenne paralysis
Results from an upper brachial plexus injury to nerve roots C and C6 - results in loss of shoulder and elbow function and weakness of the wrist and finger extensors - forms a "waiters tip" position - the arm hangs limply at the side with the shoulder internally rotated - the forearm is pronated, which slightly flexes the wrist
What are two surgical procedures for spasticity?
Rhizotomy - surgical resection of the spinal nerve Tendon Release - to reduce the frequency or magnitude of the spasticity
Neuromuscular scoliosis most common curves
Right lumbar, left thoracic
C1 stable and calloused w/ neurologic function
Rigid cervical
Shoe modification to simulate DF
Rocker bar
What are the 5 sections of the brachial plexus (in order)?
Roots, trunks, divisions, cords, and branches
Serratus anterior muscle function
Rotate scapula
Lateral bending of spine always includes
Rotation
The position of the thoracic facets most easily allows for which movements?
Rotation and lateral flexion
C1-C2 joints allow what movement
Rotation, flexion, extension
Aids the deltoid w/ gleno-humeral abdution
Rotator cuff - supraspiatus, infraspinatus, susbcaplaris, teres minor
How do you determine where to brace with fracture bracing (what joints to cover)
Rule of thirds: depending on where the fracture is in the long bone you brace the adjacent joint -if it is in the proximal 1/3 of the tibia need to go across the knee -middle 1/3 of tibia don't need to go across anything -distal 1/3 of tibia need to go across ankle
At what level is the ASIS at?
S1
PSIS is located at what spinal level?
S2
In a metal AFO w/ locked ankle what helps diminish a knee flexion moment at heel strike
SACH heel wedge
What orthotic solution may you consider for someone with Erb-Duchenne paralysis? and why?
SEWHO (shoulder elbow wrist hand orthosis, "airplane") - shoulder stabilizer - elbow orthosis, to assist elbow flexion - WHFO to augment hand function * stabilize shoulder in slight abduction * elbow supported in adjustable flex/ext. - wrist and hand, supported in a neutral ore functional position if some hand function remains
What orthotic recommendation would you have for someone with a flail arm due to a brachial plexus injury?
SEWHO- shoulder elbow wrist hand orthosis ("gunslinger") - shoulder stabilizer or positioner - elbow joint, possibly adjustable - static WHFO, or WHO with MCPJ flexion by external cable or power
What is a carlson modification?
ST shelf mod used for pes planus
True dorsiflexion and plantarflexion occur in what plane?
Sagittal
What orthotic recommendation would you give someone with a SCI with C6 escape?
Same as C7 injuries * take advantage of the functioning extensor carpi L&B with a Tenodesis splint
Name a purely sensory nerve:
Saphenous
Scarpa triangle
Sartorius, Inguinal ligament, Adductor Longus
What is the most common curve pattern for adolescent idiopathic scoliosis?
Single right thoracic
Where is plaster removed on an AFO mold?
plantar surface to match shoe contour forefoot and heel should be parallel
A mobile base of support for the arm is the
Scapula
Nerve that divides into the common peroneal and tibial nerve
Sciatic nerve
What are the phases of bone healing?
Secondary healing- (callus formation) 1.Inflammation 2. Induction 3. Soft callus 4. Hard callus 5.Remodeling
What unlocks the weight activated stance control knees? What are the downsides to this knee?
Sensor in foot plate triggers the device to lock Electronics are prone to environmental degradation Batteries make these options heavier than others
Which muscle provides upward rotation of the scapula
Serratus Anterior
What muscle does the long thoracic nerve provide innervation for?
Serratus anterior * damage will lead to winging of the scapula during a push-up
Peripheral nerve injury at the wrist of ulnar nerve would be best treated with
Short opponens w/ MP extension stop (lumbrical bar)
Lesion of tibial nerve on one side result in what deviation
Short step length on contralateral side
Complete lesion of tibial nerve will cause what deviation
Shortened step length on contralateral side
Most important acquisition of the C5 quad is
Shoulder and elbow flexion
Describe the extension synergy pattern of the arm
Shoulder protraction, adduction, internal rotation; elbow extension, pronation
Which side should the trochanter extend
Side of the decompensation
What area of the skin is innervated by the ulnar nerve (C8 and T1)?
Skin of: - 5th finger - medial half of the hand and 4th finger
Primary concern w/ a spinal injury
Skin sensitivity to pressure
When positioning the wrist for the fitting of a WHO the most functional
Slightly extended
Where are the posterior pins on a halo placed
Slightly superior to the ear opposing the anterior pins
Pt w/ flaccid anterior compartment and M/L instability
Solid Ankle PP
Patient has both knee instability at heel strike and genu recurvatum at mid stance, What AFO ankle
Solid ankle
Which AFO variety would you recommend for a patient with Fair/Zero anterior and posterior compartments and ankle joint pain?
Solid ankle - set in desired flexion angle (Rocker bottom sole helpful)
What is the difference between solid-ankle and PLS AFO trim lines?
Solid ankle trim lines are 1/4" anterior to malleoli, PLS trim lines are 1/4" posterior to malleoli Solid ankle is more rigid, whereas PLS has more energy return
Before fitting, the KAFO should be examined to assess over-all weight, craftsmanship, and appearance. What questions/things do you need to check pertaining to this?
Some questions to consider when examining: • Do the knee and ankle joints move freely within the prescribed range? • Are the medial and lateral joints congruent to one another? • Do both knee joint's lock and unlock simultaneously? • Proper rivets (minimum adult)- 2 Thigh 3 Calf
An upper motor neuron injury causes what type of paralysis?
Spastic
What is a contraindication for manually locking knee joints
Spasticity, and knee flexion contracture
Hydrocephalus often accompanies what condition?
Spina Bifida
Hydrocephalus is associated w/
Spina Bifida or Myelomeningocele
Spastic paralysis may result from
Spinal cord injury, brain injury (not cauda equina or peripheral nerve)
dermatomes are innervated by a _________ while area of skin is inervated by a ________________ nerve
Spinal nerve, peripheral nerve
Paraspinal bars on a TLSO should extend superiorly to
Spine of scapula
Superior margin of paraspinal bars in a Taylor TLSO
Spine of scapula
What is the superior margin of the paraspinal bars on a Taylor TLSO?
Spine of the scapula
what is another name for a pars fracture and where is it located?
Spondylolysis , pars interatricularlis
What should we look for in the gait analysis of the patient while wearing the KAFO
Stability in stance Clearance in swing Limb advancement Energy efficiency Compensatory strategies? Hip hiking, vaulting, circumduction, toe drag, stiff knee, etc..... Walking aids? Use of crutches, cane, or walking bars for assistance.
Patient does not have active control of knee extension during stance what type of KAFO?
Stance control
Infection control practices used to prevent transmission of diseases that can be acquired by contact with blood, bodily fluids, non-intact akin and mucous membranes are referred to as:
Standard Precautions
What orthosis would you recommend for a radial nerve palsy that has resulted in loss of wrist and MCPJ extension?
Static WHO (dorsal shell) with dynamic MCPJ extension assist (spring wires), thumb post, and dynamic wrist extension components
What orthosis would you recommend for a patient that has had a stroke which has lead to spasticity causing pronation, wrist flexion, finger flexion, thumb flexion and adduction?
Static hand finger orthosis or resting splint
What orthotic recommendation would you give someone with either thumb OA, Skier's or Game Keeper's thumb?
Static short opponens orthosis (thumb post splint)
What orthotic recommendation would you give someone with a SCI with C8 escape?
Static thumb post
Knee joint that does not require patient to manually lock the knee
Step lock knee
The axial and appendicular skeletons are attached where
Sternoclavicular and sacroiliac joints
What adjustment would you do to a shoes for claw toes on a neuropathic foot?
Stretch the tow box
Inversion and eversion of hindfoot occurs at what joint
Subtalar
What compensatory strategies would you see for a fixed forefoot varum deformity?
Subtalar pronation, plantar flexed first ray, and tibial internal rotation
You are seeing a patient who has recently relocated to the area. They are currently wearing a Cruciform Anterior Stabilization Hyperextension(CASH) orthosis. The patient states they cannot tolerate the orthosis due to pressure on an ostomy which is located at the midline of the abdomen, superior to the umbillicus. What is the best option to address this problem?
Suggest switchin to a Jewett style orthosis.
What observations should be made while the patient is standing in the checkout of a thermoform KAFO
The weight line should pass posterior to the hip, posterior to the knee and anterior to the ankle. Are the locks functioning properly? Are the uprights located along the mid-line of the limb? Is the foot plantigrade? Is the patient stable? Is the orthotic knee joint being used congruent with the anatomic knee joint? Make sure that the proximal edge isn't impeding on the perineum causing any discomfort Does it fit in shoe properly? Is there adequate space/clearance for all bony prominences? Is the patient comfortable? Check over-all stability of the patient in the frontal and sagittal planes.
LLE Lateral compartment
Superficial Peroneal Nerve - Peroneus Longus, Peroneus Brevis
Describe the posterior trim lines for a TLSO
Superior: 1" inferior to scapular spines (2 cm > anterior trim) Inferior: 1/2" to 1" above seating surface, parallel to floor, contoured to glutes
Describe the anterior trim lines for a TLSO
Superior: 1" inferior to sternal notch, parallel to floor Inferior: 1" superior to pubis, rounded convex shape
Describe the anterior trim lines for a LSO
Superior: 1" to 1 1/2" distal to xiphoid process (can be lowered if extension control is main concern) Inferior: 1" superior to pubis, rounded convex shape
Describe the lateral trim lines for a TLSO
Superior: 1" to 1 1/2" inferior to axilla (nipple line for males) Inferior: 1/2" to 1" superior to greater trochanter (angled slightly down from anterior to posterior)
Describe the posterior trim lines for a LSO
Superior: 1/2" to 1" inferior to inferior angle of scapulae (3 cm > xiphoid) Inferior: 1/2" to 1" above seating surface (leave long for larger glutes)
Describe the lateral trim lines for a LSO?
Superior: Flow from anterior to posterior Inferior: 1/2" to 1" superior to greater trochanter - Slightly angled from anterior to posterior
Secondary function of the biceps brachii, primary?
Supination 2*, Elbow Flexion 1*
What are the 4 medicare justifications for a wedge addition to a shoe?
Support, stabilization, equalized weight distribution, or balance.
Deltoid will not initiate abduction with out
Supraspinatus
Scapular abduction
Supraspinatus
The space between an axon and a dendrite is called the:
Synapse
Primary target of RA
Synovium
Name one accessory often used with a free-motion AFO joint selection.
T-strap for valgus or varus control
Scapular spine is located at what spinal level?
T3
Spine of the scapula is parallell to which vertebra
T3
Sternal notch is located at what spinal level?
T4-5
What level of paraplegia seldom gets braced
T6
Inferior angle of the scape is located at what spinal level?
T7
Xiphoid is at what spinal level
T9
Why is the free knee joint not stable in the sagittal plane
There is no lock in this plane
what are the joints of the shoulder girdle
sternoclavicular acromio clavicular glenohumeral scapulothoracic
What kind of brace for a T1 spinal cord patient?
THKAFO with drag to gait
Manage a T6, two column compression fx
TLSO A/P, M/L control
Treat a T11 anterior (20%) compression fx
TLSO Anterior control
T3 compression fx treatment
TLSO: Anterior control w/ cervical extension
The superior tarsal bone articulating w/ the tibia, fibula, calcaneous and navicular
Talus
What two joints are most often affected by Charcot disease?
Tarsometatarsal and metatarsophalangeal
Natural opposition of thumb and fingers when wrist is in extension
Tenodesis
In addition to the deltoid, the axillary nerve innervates the:
Teres Minor
Besides Deltoid, the axillary innervates
Teres minor
Maximum dorsiflexion occurs during which phase of gait?
Terminal Stance
The volar surface relates to what part of the hand?
The Palm
Patient has the potential to be a good ambulator, which section of your notes does this go in?
The assessment
The muscle length-tension relationship describes:
The concept that strength of a muscle changes depending on the affected joint's position through its arc of motion
whats the function of the interossei muscles?
They work to abduct the digits
The principles of fitting a Milwaukee TLSO:
The loading vector for thoracic and lumbar pads should be anteromedial in almost all cases
What lever system are most muscles?
Third class levers
Positive Trendelenburg sign
The non-involved side of the pelvis drops upon weight bearing on the involved side
What are the steps for the first time donning a thermoform KAFO
The patient should be sitting/lying and you want to place the affected leg into the KAFO carefully. • Make sure that back of heel is seated and back portion of the AFO section of brace securely. • Tighten all straps at ankle, calf and thigh to secure fit.
Aspects of gait:
The percent of gait spent in double limb support decreases with gait speed. Stance phase accounts for approximately 60 percent of the gait cycle. When the right leg is in loading response the left leg is in preswing.
A positive Trendelenburg sign is assigned when:
The sound side pelvis drops upon weight bearing on the affected side.
The tibial nerve supplies instruction to what part of the body?
The toes
What functions the the T6 SCI patient have over the T1 patient?
This patient has function of the core muscles allowing him to stand upright patient would be braced with HKAFOs
Which part of spine has most rotation
Thoracic
Scheurerman's disease produces
Thoracic kyphosis
If apical vertebrae at T12 is
Thoracolumbar curve
The C-Bar on a hand orthosis acts as a :
Thumb adduction stop
Blount disease is also known as:
Tibia vara
Loss of power to gastrocnemius and soleus means injury to _______ nerve
Tibial
LLE Posterior compartment
Tibial Nerve - Gastrocnemius, Soleus, Tibialis Posterior
Muscles posterior to the medial malleolus
Tibialis Posterior, Flexor Digitorum Longus, Flexor Hallucis Longus
Muscles assisting in dorsiflexion
Tibialis anterior, peroneus tertius, extensor hallucis longus
What does the ober test check for
Tightness in the tensor fascia latae or IT band.
Purpose of measuring external rotation of the ankle
To ensure mechanical and anatomical axis are the same in transverse plane
If pt only has median nerve they need
WHFO w/ MCP extension stop and IP extension assist on 4th and 5th
To give prehension to a quad with a C6 nerve root functioning
WHFO wrist driven
When would you use a heel flare?
To resist eversion or inversion of the hindfoot
What does ortho mean
To straighten
The deformity caused by unilateral contracture of the sternocleidomastoid is called:
Torticollis
Biomechanical principle for managing neuromuscular spine
Total contact
Why might you choose a thermoplastic KAFO over a conventional? Whats a negative to thermoplastic KAFOs
Total contact = improved anatomic control -Hygiene - easier to clean -Poor heat dispersion (bad for M.S.)
Describe the progression of the neuropathic foot
Trauma-> Inflammation-> Ulcer-> Infections-> Absorption -> Deformity-> Disability
Dennis Browne Bar
Treating club foot post casting
A lower motor neuron neuron injury to C7 affects what muscles?
Triceps, wrist flexors, and finger extensors
How can an orthoses trimlines prevent knee buckling
Trimlines (Conventional use 4-Buckle knee pad) prevents knee from buckling anteriorly -Thigh - High posterior and low anterior -Calf - High anterior (possibly molded shell)
Where should the trimlines be on an internal upright? Why?
Trimlines must include joint head want to laminate or thermoform over joint heads screw points are high stress point likely to fracture -why we integrate it into the lamination
T/F. The majority of amputations are caused by gangrene
True
What type of diabetes is insulin Dependent
Type 1
What type of diabetes is non-insulin dependent
Type 2
Charcot Marie tooth
Type I & II hereditary motor and sensory neuropathy, bilateral pes cavus, atrophy, foot drop
Flexor synergy pattern upper extremity and lower extremity
UE: Abduction, External rotation, elbow flexion, forearm supination, and wrist flexion LE: hip flexion, abduction, external rotation, knee flexion, dorsi flexion and inversion
Describe extensor synergy pattern of UE and LE
UE: shoulder adduction, internal rotation, elbow extension, forearm prontation, wrist flexion LE: Hip extension, adduction, IR, plantar flexion
C5 complete quadriplegic needs what type of orthosis
WHO w/ external powered wrist
What is most appropriate for a median nerve injury at the wrist?
WHO with thumb post
What vessel does the ulnar nerve parallel in the forearm?
Ulnar artery
What ligament is damaged in a Skier's or Gamekeepers thumb?
Ulnar collateral ligament (medial collateral ligament)
What deformity is the primary orthotic consideration with Rheumatoid arthritis?
Ulnar drift due to damage to the MCP joints
What nerve is being tested with Froment's test?
Ulnar nerve * inability to adduct the thumb, compensates with flexion
Froment's test
Ulnar nerve test
What gait deviation would you primarily expect to see with a tibial nerve lesion?
Uncontrolled tibial advancement in stance phase
Upward rotation of the scapula is produced by
Upper and middle segments of trapezuis and serratus anterior
Erb's Palsy is injury to
Upper trunk of brachial plexus
The UCBL orthosis will tend to correct
Valgus of the knee and ankle
How do you establish frontal plane alignment on an AFO mold?
Vertical line bisects calcaneous and middle and medial thirds of calf
Which term best pertains to the palm of the hand and the sole of the foot?
Volar
____ pertains to the palm of the hand or the sole of the foot
Volar
Where are the wrist flexors
Volar forearm
Where is the weight line in the scott-craig KAFO
Weight line falls anterior to ankle, posterior to hip and knee. this is ok because the KAFO is locked at these joints
When do you bill the hospital?
When patient has both Medicare part A and B
Nerve plexus
When two or more spinal segments intermingle and segregate in order to travel together as a nerve bundle to a similar anatomical region
When is the hip most stable
When weight line is posterior (in extension)
When should a quadriplegic be fitted w/ an upper limb orthosis
While the pt is on a Stryker Frame
what determines the width of the posterior opening of the boston brace?
Width of L5
What is the formula for the cranial index?
Width/Length*100
Arthrogryposis
Wooden doll appearance, goals - feel plantargrade, knees extended, hip extended
What orthosis would best restore upper extremity function for a patient with a spinal cord injury above the C6 nerve root?
Wrist driven WHO
What orthotic solution may you consider for someone with Klumpke's paralysis? and why?
Wrist driven flexor hinge hand orthosis - tenodesis splint - in order to stabilize the wrist and provide a pinch grip
What orthotic recommendation would you give someone with a SCI with C7 escape?
Wrist driven flexor hinge hand orthosis (tenodesis splint) - ideal for this level of injury
What are the correct joint positions when casting for a WHO?
Wrist extended to 20 degrees, MCPs flexed 35-40 degrees, PIP and DIP slightly flexed, thumb in partial opposition (to 2nd and 3rd finger)
Lateral cord function, tear causes weakness in
Wrist extension
Describe the functional position of the hand and wrist
Wrist: extended 20 degrees, ulnarly deviated 10 degrees. Digits 2 through 5, MPs flexed 45 degrees, PIP flexed 30-45 degrees, DIP flexed 10-20 degrees. Thumb abducted and opposed to 2nd finger, MP flexed 20 degrees, IP flexed 5 degrees,
Doctor writing you LOMN wants you SOAP, what do you need
Written release of the pt
What knee type are stance control knees (poly, single)
polycentric
If the practitioners facility is designated as a participating supplier, this means that:
You must accept the Medicare allowable amount as payment in full.
How should a GRAFO be aligned in the sagittal plane
a few degrees of PF
Brown-Sequard Syndrome
a neurologic condition which has a lesion in the spinal cord which results in weakness or paralysis on one side of the body and loss of sensation on the opposite side
What is the prime elbow flexor?
a. Brachialis
What happens if a PLS is too stiff for a hemiplegic child?
acts as a tight heel cord and causes a hyperextension moment
Name the parts of the scapula
a. Glenoid cavity b. Coracoid process c. Acromion process
Name 3 things about Sheurmann's kyphosis:
a. It may be treated using a Milwaukee CTLSO b. It is a sagittal plane deformity c. It is an idiopathic juvenile disorder
The adductors of the scapula include:
a. Middle trapezius b. Rhomboids c. Latissimus dorsi
What are examples of Upper motor neuron disease
a. Multiple Sclerosis b. Cerebral Palsy c. Cerebrovascular Accident
oblique fx
bone breaks diagonally
comminuted fracture
bone breaks into many fragments
spiral fx
bone has been twisted apart and the fracture spirals around the long axis
Which are some biarticular muscles:
a. Semitendinosis b. Biceps femoris c. Rectus femoris not vastus medialis
what can be done to stop hyperextension after the brace has already been fabricated?
add a posterior criss cross strap add a heel wedge add padding to calf band to make slightly more shallow increase amount of dorsiflexion by adjusting PF stop
one way to increase strength of a solid ankle afo
add corugations
Decorticate is what type of synergistic pattern
abnormal flexor response rigidity seen after cns injury
at what age does a baby begin walking
about 12 months
Obturator Nerve
adductor longus adductor brevis adductor Magnus obturator externes gracilis
What does the obturator nerve innervate?
adductor muscles
List the prehension patterns:
a. cylindrical b. tip c. hook or snap d. jaw chuck e. spherical f. lateral
Where does the adductor magnus insert?
adductor tubercle
shoulder internal rotation muscles
anterior deltoid pec major subscap teres major lats
how is supination addressed in talipes equino varus
abducting the foot under the talus
lateral plantar nerve (tibial nerve)
abductor digiti minimi flexor digiti minimi oppenens digiti minimi dorsal interossei quadratus plantae adductor hallucis lumbrical II, III, IV plantar interossei
medial plantar nerve (tibial nerve)
abductor hallucis lumbrical I flexor digitorum brevis flexor hallucis brevis
at what age does the medial longitudinal arch develop?
age 6
How would you align an LSO for a patient with lower lumbar spinal stenosis? Why?
aligned in flexion. This will allow the spinal canal to decrease occlusion
How does Decerebrate rigidity present
all extremities extended indicative of damage to more caudal areas
Patient using metal and leather KAFo with drop locks and DAAJ comments of feeling unsteady and frequently trips when going down ramps. What adjustments would you make?
allow for PF moment at ankle provide DF assist cushion heel to shoe
What motions does williams flexion LSO limited? What would you use it for?
allows free flexion but limits extension could use for spondylolisthesis
What are other names for a bail lock
also called CAM lock, swiss lock, French lock
L4 myotome
ankle dorsiflexion
humeral flexion muscles
ant delt pec major coracobrachialis biceps
what does the deep peroneal nerve innervate?
anterior leg muscles
What are the ligaments of the lateral ankle?
anterior talofibular, calcaneofibular, posterior talofibular
what muscles in gait are used to achieve dorsi flexion?
anterior tib, extensor hallucis longus, extesor digitorum longus
What would contraindicate orthotic treatment for a patient with spondylolisthesis?
anterior translation of superior vertebra by over 50% superior vertebrae angulation of over 50 degrees
Jewett and cash brace indications
anterior vertebral body fx at T5- L5 DDD ankylosing spondylitis kyphosis due to osteoporosis Reumatic arthritis
Definer upper motor neuron
any neuron involved in conveying motor impulses from the brain to the anterior horn cells of the spinal cord
What two deformities occur with injury to median nerve?
ape hand and hand of benediction
Where is the lumbar pad located on a boston brace?
apical lumbar vertebra downward to all the verts slanted in the same direction
where is the thoracic pad located on a boston brace?
apical thoracic vertebrae down to the crest roll
middle cerebral artery stroke affect arm or leg more?
arm
what are four clinical visible by the eye signs of scoliosis
arm gap, pelvic obliquity, rib hump, prominent scapula
Patient has severe chronic bilateral posterior tibialis tendon dysfuncton. UCBLS have been ineffective what would you reccomdend now
articulated afo
greenstick fracture (incomplete fracture)
bone that is broken only on one side and the other side is bent. Happens in children because of thick periosteum
Why is fabrication quality key with internal uprights
they are not adjustable
what functional characteristics must a patient have to be considered for a stance control KAFO?
at least 3/5 at the hip extensors and flexors full extension at the anatomical knee joint
What results when the extrapyramidal system is injured?
athetosis
what nerve innervates the deltoid and teres minor
axillary
What nerve innervates the Lats
thoracodorsal nerve
patient has difficulty with roll over using an atriculated afo with full footplate. What are two recommendations
cut footplate to sulcus rocker bottom shoes
type of prehension provided by a wrist driven tenodesis orthosis?
three jaw chuck
How is protocol different in a halo on a pediatric patient
use more pins with less torque
What can happen internally to the free knee joint allowing the knee to go into hyperextension
because joint stops in full extension; there is a part in the joint that stops hyperextension; if this wears out the patient would be able to hyperextend Can tell if the central screw is worn out if there is a gap between proximal and distal section in full extension
sciatic nerve- common peroneal division
biceps femoris (short head)
elbow flexors muscles
biceps, brachialis, brachioradialis, pronator teres
L5 myotome
big toe extension
Parkinson's affects what part of the brain?
basal ganglia
what is a jones fracture
break between the base and middle part of the fifth met
How does an rgo allow forward progression
by harnessing energy from one hips extension and translating into contralateral hip flexion
advantages of a metal KAFO vs plastic
durability and adjustability
3 characteristics of torticollis?
contracture of the sternocleidomastoid muscle ipsilateral head tilt contralateral head rotation
In scoliosis the vertebral body rotates toward the __________ and the spinal process rotates toward from the ___________ of the curve
convexity, concavity
At what section of the brachial plexus are the nerve route bundles classified based on their orientation with the axillary artery?
cords *lateral, posterior, and medial
What is an indication for the use of a GRAFO?
crouch gait
When would you use a Milwaukee TLSO for scoli
curves with an apex of T7 or higher
L1 burst fx whats the most appropriate orthosis?
custom polymer TLSO
What spinal segments contribute to the brachial plexus?
c5, c6, c7, c8, T1
disadvantage of a thermoplastic kafo
can be hot to wear
Why might you use a posterior offset joint
can use it instead of a lock for patients with hyperextension put the anatomical knee anterior to the axis of rotation of the knee joint (mechanical axis posterior to anatomical axis)
what 3 regions of the brain control motor activity?
cerebral cortex cerebellum basal ganglia
what part of the brain is involved with ataxia?
cerrebellum
C1, C2 Myotome?
cervical flexion
C3 myotome
cervical lateral flexion
Describe adhesive capsulitis
characterized by restriction in shoulder motion in external rotation, abduction and flexion inflammation and fibrosis at shoulder
What pathologies would a patellar tendon bearin afo be indicated for?
charcot joint, avascular necrosis of the talus, OA of the ankle joint, calcaneal fracture
plegia means what?
complete paralysis
Purpose of the axillary extension in a boston brace?
contacts the lateral aspect of the upper thoracic ribs from one vertebral level above the apex
Which of the following Orthoses is designed to manage spondylolisthesis in an active teenage? a. Corset, b. Knight, c. Jewitt, d. Anterior Overlap LSO
d. Anterior Overlap LSO
Whats another name for a double action ankle joint?
double klenzak joint
What type of control do double uprights give (which plane)
double upright gives medial and lateral control for axial loading
Indications of posterior leaf spring?
drop foot, poor swing phase clearance, mild crouch gait type 1 hemiplegia, mild diplegia
What does Erb's Palsy affect? and what spinal nerves
decreased shoulder girdle function. C5-C6
what is a sesamoid platform used for
decresses excessive pressure on the head of the first med by transferring some pressure to the shaft.
for spondylolisthesis should an LSO increase lodosis or decrease it
decrease
For lumbar DJD should an LSO increase lumbar lordosis or decrease it?
decrease.
What does the stability of an upright depend on?
depends on how thick the upright is
what does the yergason test for?
determines if the biceps tendon is stable in the bicipital groove
whats a colles fx
distal radius fx
how do you find the anatomic waist
distance between the inferior costal margin and the iliac crest divided by two
At what section of the brachial plexus do the nerves form into flexor (anterior), and extensor (posterior) compartments?
divisions
what nerve innervates the rhomboid and levator scap
dorsal scapular nerve
Patient has PVD. What is a common artery to asses blood flow?
dorsalis pedis
what are the features of a klenzak joint?
dorsi flexion assist and plantar flexion stop
pronation of the ankle is comprised of what motions?
dorsi flexion, valgum, eversion of the forefoot
Should the material of a willams flexion brace be fabricated out of elastic or inelastic material?
elastic so it doesnt limit flexion
C7 myotome
elbow extension, wrist flexion
what is the primary function of the brachioradialis?
elbow flexion
C6 myotome
elbow flexion, wrist extension
Injury to the anterior division of the brachial plexus would cause weakness of what muscles?
elbow flexors wrist flexors forearm pronators thumb abductors
When fabricating a KAFO the distal posterior thigh and the proximal posterior calf should be located where?
equidistant from the knee joint center
describe avascular necrosis
etiologies resulting in lack of blood flow to the femoral head Arom is decreased in hip flexion, IR, and abduction pain at groin and thigh, tenderness at hip
Describe avascular necrosis
etiologies resulting in lack of blood supply to the femoral head, AROM is decreased in hip flexion, internal rotation, abduction, pain in groin, thigh, tenderness at hip
Cause of sub-calcaneal bursitis
excess eversion of the calcaneus causes the medial tuberosity to bear on the bursa during heel strike
How is a mortons neuroma formed?
excess pronation elevates first met and puts excess pressure on plantar intermetatarsal nerves
excessive supination has what related deviations
excessive forefoot adduction calcaneal varus 5th met head discomfort 1st met containment lateral sabolich mod
what is the cause of plantar fasciitis?
excessive lengthening of the plantar fascia occurs when people increase physical activity
The median nerve innervates all of the flexors of the forearm expect___________-
flexor carpi ulnaris
A patient with a complete C6 spinal cord injury powers a wrist-driven flexor hinge tenodesis orthosis by using the
extensor digitorum communis and extensor carpi ulnaris
What two muscles make up the borders of the snuff box?
extensor pollics longus, and extensor pollics brevis
What position does the lower extrem move into during legg calve perthes
external rotation, flexion, and adduction
What kind of fall may cause a scaphoid fx
fall on out stretched hand
what nerve innervates the knee extensors
femoral nerve
what structures are found with in scarpas triangle
femoral nerve, femoral artery, sartorius muscle, inguinal lymph nodes, adductor longus, inguinal ligament
All the landmarks to mark on your stockinette for an afo
fib head and neck tibial crest? malleoli calcaneal tuberosity if prominent base of 5th met navicular met heads toe sulcus
T1 myotome
finger abduction
What are some contraindications for a stance control knee KAFO?
fixed hip or knee flexion contracture fixed plantar flexion contracture significant spasticity leg length discrepancy greater than 3 inches varus or valgus deformity greater than 10 degrees excessive body weight (above 220)
injury to lower motor neuron causes what
flaccid paraylsis on the same side of the body
How to perform the Silver Skol test
flex knee and dorsi flex the ankle. Begin extending the knee and if foot plantar flexes its a positive sign of a tight gastroc
what is the function of lumbricals?
flex the MP joints and extend the IP joints
How would you position a patient to reduce lumbar lordosis in standing?
flex the knees flex the hips
What are the indications for a ucbl
flexible calcaneal valgus or varus of greater than 15 degrees mild or moderate spasticity
Boutonniere deformity
flexion of PIP joint and hyperextension of DIP joint
disadvantages of a metal KAFO vs plastic
heavier and less cosmetic must be attached to shoe less contact points for control
rx for fixed equinus
heel elevation to reduce met load contra lateral heel lift
steel sole bar
helps reduce stress at the phalanges and metatarsals often used with rocker bottom
claw, hammer and mallet toes rx
high toe box lower heel height toe crest met pad steel sole bar
hallux valgus rx
high wide toe box lower heel height to transfer pressure to heel ML arch support
Describe extension synergy of the leg
hip extension, adduction, and internal rotation; knee extension
L1-L2 myotome
hip flexion
What does the Thomas test test for?
hip flexion contracture
Swan neck deformity
hyperextension of PIP joint and flexion of DIP joint
Why do we want to use a single upright with genu valgum patients
if this is the case single upright is better so there is not impingement on the ankles knee -Not anymore lightweight than double upright -single upright increase bulk since its only one (made of steel to increase strength)
Why is a drop lock knee joint hard to unlock when loaded (spasticity)
if uprights are contoured for contraction and lock is engaged you will have a flexion moment on lock at all time You will not be able to unlock joint here. Need to then put an extension moment on joint to unlock it. Therefore need to set the lock just shy of full extension
what are some benefits to a stance control KAFO?
improve walking speed, cadence, and step length improves symmetry of gait decreases compensatory movement safer management of inclines
When would DF and PF assists be contraindicated in a conventional afo?
in the presence of severe spasticity, paralysis, and joint instability
Why does flaccid paralysis in spina bifida occur?
incomplete closure of the neural tube during embryonic phase prevents connection between spinal cord and muscles
What is asia C?
incomplete motor function but more than half of muscles are a grade 3 or less
posterior trimlines of LSO
inferior angle of scapular to sacrococcyxeal jont
humeral external rotation muscles
infraspinatus teres minor post delt
Posterior tibial tendonitis can present with what?
inversion weakness, inability to perform heel raise, and tenderness under the medial malleoli. can also cause tingling at the medial side of the foot due to impingment of the tibia nerve
Where is it a posterior offset joint positioned relative to someones weight line
joint is posterior to weight-line of patient put the anatomical knee anterior to the axis of rotation of the knee joint (mechanical axis posterior to anatomical axis)
patient has anterior distal thigh pressure when sitting with KAFO?
joints are too distal
patient has discomfort along posterior distal thigh when sitting on a kafo?
joints are too proximal
What is the ultra flex joint? What are its benefits?
joints use concentric torsion mechanism provides extension moment accross the knee provides low load over a long period of time can't ambulate with them
where is a tailors bunion located and what is the cause?
just behind fifth met caused by over pronation
patient has AVN of the femoral condyles why type of brace would you use?
kafo with ischial weight bearing brim
What braces would you use for a T12 complete SCI patient?
kafos
3 biomechanical principles of an LSO corset
kinesthetic reminder increased intra-abdominal pressure three point pressure systems
L3 myotome
knee extension
what muscles groups regain strength first for ppl recovering from guillain-barre?
knee extensors and flexors
S2 myotome
knee flexion
What degree of knee flexion contracture cause the GRF to be posterior to the knee for all of stance phase?
knee flexion contracture of ten degrees
at heel strike what position is the knee in and what position is the ankle in
knee is at neutral and ankle is at 90
What is a contraindication for a stance control 4-bar knee joint
knee or hip flexion contracture
Hypotonicity is what?
lack of manual muscle co-contraction acute injury to the CNS
purpose of a lateral sole wedge and a medial sole wedge
lateral - everts/pronates foot medial wedge - inverts or supinates the foot
Where are the anterior pins on a halo located?
lateral 1/3 of eyebrow just above eyebrow
what are the three arches of the foot?
lateral longitudinal arch medial longitudinal arch tranverse metatarsal arch
How would you fabricate the AFO section of a KAFo for a patient with a varus moment?
lateral sabolich modification 1st met head containment utilize a padded T strap (attached laterall with a medial chafe)
Valgus correction strap wraps around which upright?
lateral upright
Where are most stance control knee joints placed on a KAFO?
lateral upright
3 point for system of a solid ankle afo for varus
laterally directed for at proximal calf laterally directed force along 1st metatarsal medially directed force at either side of the malleolus
How do you perform the thomas test and how do you measure the contracture?
laying supine, bring both legs to chest, lower one leg while keeping the other one flexed. You measure the angle between the leg and the table to figure out the contracture
What are some red flags of scoliosis?
left thoracic curves hairy patches cavus foot inability to get hands down significant back pain
Does anterior cerebral stroke affect the arm or the leg more?
leg
when would you use a heel lift
leg length discrepancy or fixed equinus
muscles involved in scap downward rotation
levator scap rhomboids pec minor
Why is the bail placed where it is on the orthosis? How do we instruct patients to use it?
lever specifically put in this spot so it hits a chair top tell patient to flex hip, bear weight on sound side, and lower to chair which will hit lock to unlock joint
advantages of a thermoplastic kafo
lightweight interchangeability of shoes greater cosmesis
What is a Posterior knee strap (cris-cross)
like a four buckle knee pad flipped posterior to prevent the knee from going backward
How does a pinch callus form?
lmited dorsiflexion of the MTP joint because of overpronation. foot is externally rotated during pre swing which causes shear forces to occur at the medial aspect of the foot
What is a step-lock? When might we use one
locks in 15º increments 7 or ten clicks -for patient who cant get into full extension when seated but can eventually get there when walking -won't unlock during swing phase (only stance control locks do this) -locking the knee can cause gait deviations
What is the talocalcaneal angle?
long axis of the talus and plantar surface of the calcaneous is 45 degrees
what nerve innervates the serratus anterior and rhomboids
long thoracic (SALT)
A posterior offset joint is most suitable for patient with what kind of disease/defficeincy?
lower motor neuron disease or low thoracic upper lumbar SCI
UCBL
maintains optimal position of the calcaneus relative to the talus -stabilizes the intertarsal and tarsometatarsal joints.
Where is plaster added on an AFO mold?
malleoli fib head base of 5th met head of the 1st and 5th mets navicular any other boney anomalies trimlines
Patient has anterior thigh pressure when sitting with KAFO. what improper joint placement could cause this?
mechanical knee joint too distal
what are the nerves in the medial cord of the brachial plexus?
medial median ulnar
Hand placement for AFO casting
medial hand on calcaneous and lateral hand on forefoot.
rx for fixed equino varus
medial heel and sole wedge heel elevation
What ligaments are in the deltoid ligament? what side of the ankle is it on?
medial side of foot anterior tibiotalar ligament tibiocalcaneal ligament posterior tibiotalar ligament
varus correction strap wraps around which upright?
medial upright
Three additions to an AFO to decrease excessive pronation within the afo?
medial wedge medial sabolich ST pad
3 point for system of a solid ankle afo for valgus
medially directed for at proximal calf medially directed force along 5th metatarsal lateraly directed force at either side of the malleolus
metatarsalgia rx
met pad
What disorder can cause toe out without femoral anteversion?
metatarsus adductus
what are 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 muslce pump aids in circulation
What are the indications for an SMO?
mild neuromuscular disorder frontal plane instability and mild sagittal plane child who is beginning to ambulate used as a transition from articulating AFO as stability improves
contraidications of a PLS
moderate to severe crouch gait, sever flexor or extensor tone, severe varus/valgus
mortons foot rx
mortons extension
Why do we want shallow distal thigh and calf bands with genu recurvatum patients
move calf band anterior to keep them out of hyperextension
What are the nerves are in the lateral cord of the brachial plexus?
musculocutaneous median lateral
Define lower motor neuron
neuron involved in conveying motor impulses from the spinal cord to the skeletal muscle
axial alignment in an adult
neutral hip slight internal rotation genu varum 7 degrees 0-10 degrees of dorsiflexion
Is an electronic locking knee the same as stance control
no
Would a patient with left hemiplegia respond well to demonstration and gesture?
no
Purely athetosis is an injury to the extra pyramidal and results in what?
normal voluntary control damage automatic control patterns of activity could not be correctly stored
What is a stance control 4-bar knee joint
not a different type of activation just a different design polycentric rather than single axis like the others • Use of W.B. design enhances performance • Posterior cable disengages lock when pulled.
transverse fx
occurs in a straight line, direct blow (bending)
Which orthotic ankle joint has a true articulation
oklahoma joint single axis
How should a childs hips be oriented when wearing a pavlik harness?
oriented in flexion and abduction
What is ataxia?
oscillation of extremities and or trunk during diffiuclt tasks
metatarsus adductus rx
outflare last
rx for talipes equino varus
outflare last lateral heel and sole wedge reverse tomas heel long medial coounter lower the heel
cause for tibial anterior tendonitis
over pronation tibialis anterior is working harder to stabilize the medial arch
cause of achilles tendonitis
over pronation of the foot results in lateral edge of calcaneus to irritate the tendon
paraplegia
paralysis from the waist down
quadriplegia
paralysis of all four limbs
hemiplegia means what
paralysis of one side of the body
paresis means what
partial or incomplete paralysis
What is a prerequisite for using an articulating AFO
patient needs to have 5 degrees of true dorsi flexion
What is gowers sign and what patient is it most common in?
patient walks hands up legs to get upright. common in muscular dystrophy
scapular protractors
pec minor serratus anterior
muscles involved in scapular depression?
pectoralis miner and lower traps
what nerve innervates the dorsiflexors
peroneal nerve
Superficial peroneal nerve
peroneus longus peroneus brevis
What is the cause of a heel spur?
plantar fascia pulls away from the calcaneus resulting in ossification of the bone caused by tight plantar fascia
3 point force system of a solid ankle afo resisting dorsi flexion in stance
posterior directed force at the velcro calf strap inferior directed force at the ventral met heads provided by the toe box of the shoe superior/anterior directed force at the heel
Which kafo joints prevent knee hyperextension the most easily?
posterior offset drop/bail locks
At initial contact the body weight line is where in relation to the knee and ankle?
posterior to the ankle and posterior to the knee
where is the GRF located at the knee at midstance in a patient with crouch gait?
posterior to the knee causing a flexion moment
In stnading, the gastroc help move the body ________ while the anterior tib help move the body ____________
posterior, anterior
What part of the lower leg does the tibial nerve innervate?
posterior. weak plantar flexion
3 point force system of a metal KAFO controlling knee flexion
posteriorly directed force at the knee from the 4 buckle knee pad anteriorly directed force at the proximal thigh band anteriorly directed for at the posterior distal ankle
when would you use a MP extension stop?
presence of a claw hand can be used with IP extension assist
6 year old girl with spina bifida. patient has club foot and a 30 degree scoli curve. what are some treatment goals
prevent contractures with hydrocephalus, decompress and place shunt in place prevent pressure sores fit patient with an AFO and a TLSO
Why do we want knee joints with a built in 180 degree extension stop with genu recurvatum patients
prevent hyperextension compliance may not be good with this as they are so used to resting in hyperextension to help with this can gradually adjust it in increments to ease them out of hyperextension
Primary funciton of an articulated AFO
prevent plantar flexion unrestricted dorsi flexion adjustable DF most versatile design
3 point force system of a solid ankle afo resisting plantar flexion
primary force: posteior-inferior directed anterior to axis of ankle joint (shoe) Counter force: superior directed plantar surface of footplate and toes counter force: anterior directed at the calf
What is a pro and con for the drop lock knee
pro: nothing usually breaks con: hard to unlock
which way does guillain barre syndrom progress? which direction does it recover?
progresses in ascending order (distal to proximal) recovers in descending order (proximal to distal)
What does the median nerve innervate?
pronator teres flexor carpi radialis palmaris longus flexor digitorum superficialis
hip extension gravity present
prone have patient perform hip extension then apply downward directed for at distal thigh
knee flexion with gravity present MMT
prone apply anterior force against posterior aspect of ankle
Femoral anteversion starting position, ROM, axis, and motion
prone with hip extended and knee flexed to 90 ROM is 20 axis is mid patella rotate the limb to the point of max trochanteric prominence
Checking for toe out
prone with hip extended and knee flexed to 90, looking at the angle between the heel and the thigh
Trochanter extension purpose?
provides balance for the brace and avoids sideward tilting relative to the pelvis
What is a Mondo joint? What is its downside/upside?
provides unidirectional joint motion. infinite amount of locking points downside very thick hard to adjust
what does the straight leg raise test for and what is the normal ROM
proximal hamstring tightness, should be 90 degrees, supine position
The oppenens bar should be located where?
proximal to the thumb MP joint
anterior trimlines of TLSO
pubic symphysis to sternal notch
how can you correct varus and valgus after a kafo has already been fabricated
pull strap around knee (5 buckle knee pad) add padding at medial or lateral knee to push knee in a corrected position
Spasticity results from injury to what system?
pyramidal
Five types of hyperreflexia
quick stretch slow stretch limb position in space body position in space mid-brain extra pyramidal.
Wrip drop, paralysis to the triceps, brachipradialis, supinator, and extensors of the wrist is likely caused by an injury to what nerve
radial nerve
what is the most commonly injured peripheral nerve?
radial nerve
What does the duncan eely test for
rectus femoris spasticity hip will rise when knee is flexed rapidly.
A GRAFO is contraindicated for patients with what?
recurvatum at the knee or cruciate ligament insufficiency
How do you unlock a drop lock knee joint (what force do you need)
requires an extension moment
What does Klumpke's Palsy cause? and what spinal nerves are involved?
results in decreased hand and wrist function due to the involvement of C8-T1
Describe a flexion synergy pattern of the arm
retraction, abduction (to 90degrees), and external rotation of the shoulder; flexion and supination of the elbow
Hallux Rigidus rx
rocker bar mortons extension steel sole
dorsi flexion ROM, starting position, motion
rom is 20 degrees, supine knee bent, align subtalar neutral to slight inversion while dorsi flexing
hind foot eversion/inversion ROM, starting position, axis
rom is 5 degrees, starting position is prone, axis is posterior calcaneous
what are the 5 sections of the brachial plexus
roots, trunks, divisions, cords, and branches
What is a medial wedge designed to do?
rotate the hindfoot into inversion
What is a contraindication for ankle activated stance control knees? Why?
s/p ankle fusion, OA, infection, bilateral use Patient has to be able to actively control what happens at the ankle The ankle going into DF pulls on an internal cable and unlocks the knee joint With stance control don't want the same activation type on both legs if bilateral user
what is the nominate bone of the pelvic girdle?
sacrum
First CMC joint is
saddle joint
What type of orthosis is used for a midshaft humeral fracture
sarmiento humeral fracture orthosis
Posterior trimlines of a TLSO
scapular spine to sacrococcygeal joint
what nerve innervates the hip extensors
sciatic nerve
Pyramidal is the ___________ control system while _____________extra pyramidal is the _____________ control system
selective, automatic
sciatic nerve- tibial divison
semintendinosus semimembranosus biceps femoris (long head)
what muscles does the sciatic nerve innervate
semitendinosis, biceps femoris, semimembranosis
avulsion fx
separation of a bone fragemnt from its cortex at an attachment of a ligament or tendon, powerful twist or stretch of a body part
what are contraindications of a ucbl
severe spasticity vertical talus severe mid foot break (abduction of forefoot)
Purpose of a rocker bar shoe mod
shifts the rollow over point posterior to the posterior to the met head -shifts pressure to the met shafts -decreases push off
What are the functions of weight acceptance?
shock absorption, limb stabilization, forward travel without interruption, balance on one limb
Tibial nerve
soleus popliteus plantaris tibialis posterior gastrocnemius flexor hallucis longus flexor digitorum longus
What braces for an L3 spinal cord injury patient?
solid ankles
What are some aspects of klippel-feil syndrome
short neck, low posterior hairline, and fusion of cervical vertebrae
Knee extension ROM, starting posistion, axis
should be 0 degrees, can be prone or supine, and extend the knee
C5 myotome
shoulder abduction. giving a high 5 to a midget
C4 myotome
shoulder shrug. C4??????
Hip abduction/adduction with gravity present
side lying have patient perform motion apply for along distal thigh medial thigh for adduction lateral thigh for abduction
contraidication of a thermoplastic kafo vs a metal
significant obesity fluctuating edema
dorsi flexion MMT gravity present
sitting apply pressure to dorsum of foot while using contralateral hand to stabilize the leg.
knee extension gravity present MMT
sitting apply downward force against ankle and stabilize distal thigh with the other hand
Forefoot inversion/eversion ROM, starting position, and axis
sitting or supine, 35 for inversion, 15 for eversion, axis is midway between malleoli,
hip internal and external rotation with gravity present MMT
sitting with legs hanging apply for at medial or lateral aspect of foot while stability opposite side of the knee
Hip flexion gravity present MMT
sitting with legs hanging off table have patient perform motion then apply downward force against distal end of thigh
Internal and external rotation starting position, ROM, and axis
sitting, 45 degrees, axis is the patella
Describe the clasp-knife response.
spastic limb gives way after initial period of resisting passive movement
injury to upper motor neuron causes what
spastic paralysis of the opposite side of the body
What is the scott craig KAFO?
specific design of KAFO for paraplegics the orthosis is meant for patient with posterior trunk lean (not anterior!)
What musces rotate the spine?
splenius
Patient has bilateral 3/8 heel lifts for achilles tendonitis. What lumbar pathologies could this aggravate
spondylolithesis, spondylolisis, DJD of the facet joints
DAAJ for dorsi assist
springs in the posterior channels
what percent of the gait cycle are stance and swing
stance=60 swing=40
What are some knee components that can be used to assist patients with a contracture
step-lock adjustable extension knee joint ultraflex joints Monodos
What functions does a T1 SCI complete patient have?
still has full innervation of the upper limb musculature
What is the primary function of a posterior leaf spring?
substitues for the anterior compartment muscles decelerates foot drop facilitates swing phase clearance
what joint are aligned in neutral in subtalar neutral?
subtalar, talonavicular, and calcaneocuboid
what nerve innervates hip abductors
superior gluteal nerve
what nerve innervates the gluteus medius
superior gluteal nerve
Hip Abduction starting position, ROM, and axis of rotation
supine, 45 ab and 30 ad, axis is the asis
purpose of a thomas heel
supports the medial longitudinal arch
what nerve innervates the supraspinatues and infra spinatues
suprascapular nerve
deltoid acts to abduct the shoulder with what other muscle
supraspinatus
What does the suprascapular nerve innervate?
supraspinatus and infraspinatus
The distal aspect of the tibia articulated with the:
talus and fibula
What does the thompson test test for?
tests for achilles rupture squeez gastroc and foot PFs
Damage to which nerve causes Carpal Tunnel Syndrome?
the median nerve
In an AFO, trimming the footplate proximal to the met heads will MOST effect which rocker?
the third rocker
4 ways spasticity is managed
therapeutic medication - baclofin nerve blocks surgery radiofrequency rhizotomy
thermoplastic vs metal KAFO which has better rotational control?
thermoplastic
what does the relative rigidity of a plastic brace depend on?
type of plastic thickness shape of brace
rx for pes planovalgus
ucbl thomas heel and medial counter medial heel wedge heel seat
clawhand is due to damage to what nerve?
ulnar nerve
How does decorticate rigidity present?
upper extremities are tightly flexed and lower are extended
what are the nerves in the posterior cord of the brachial plexus?
upper subscap thoracodorsal lower subscap axillary radial
where do you place the axillary extension on a boston TLSO for scoliosis
upper thoracic vertebra with a segmental vertebral tilt in the same direction.
what muscles perform scapular elevation?
upper traps and levator scap
how would you screen for a L4-5 myotome
walk on heels
How would you screen a patient for S1 mytome?
walk on toes (Plantar flexion)
What is the purpose of a weight bearing KAFO
want to offload distal aspen of the limb
What are signs of congenital scoliosis?
wedge, bar, and hemi-vertebrae
What is sheurmann's kyphosis?
wedging of at least 3 consecutive vertebrae end plate irregularities disc space narrowing kyphosis of greater than 45 degrees
Why is ankle activated stance control "redundant"
weight activated and ankle activated
When would you consider a KAFO vs an AFO
when there is hyperextension of the knee when there is excessive varus or valgus angulation that occurs when weight bearing
What type of WHO for a c6 complete sci patient?
wrist driven flexor hinge
Patient has right radial nerve intact with severed median and ulnar nerves. What orthosis and why
wrist driver flexor hinge will capture the extensor motion and transfer it to three point palmer prehension
What action occurs for a patient with c6 quadriplegia to use a tenodesis grip?
wrist extension with allows passive MP flexion
anterior trimlines of LSO
xphoid to pubic symphysis
Does duration of double support vary with speed of walking?
yes
How does a trigger lock/drop with lift loop knee joint work
• Automatic lock • Proximal release (trigger mounted at midfemur) • Difficult to unlock under load (can easily get caught on something and unlock by accident; need to make a cover for it out of leather)
What are some examples of coronal plane deformities that we may treat with a free knee and ankle joint KAFO
• Ligamentous laxity • Osteoarthritis • Rickets* • Paget's Disease* • Blount's Disease*
Describe the physical structure of the scott-craig KAFO
• Locked knee • Anterior calf band (stabilizes tibia keeping the knee from buckling) • Reinforced stirrup (very thick)
What is a polycentric knee joint? What are its benefits?
• Mimics anatomic knee motion • Useful in treating fractures or accommodating large ROM (sports; good for athletes) • Less protrusion during flexion (can get >105º)
Why would you use a double upright KAFO
• Most stable in all planes • Necessary for axial loading • Recommended for locking knee joints
What is a bail lock? How does it work? When should we use it? When shouldn't we?
• One motion unlocks both joints. • Allows hands-free operation. • Great for severe UE impairment (meant for those with upper extremity involvement) • May inadvertantly unlock (Would never be used bilaterally; Could do a bail on one side and an anterior relief on the other side)
How do you check the flexion of the knee joint in fitting
• Passively flexing the KAFO with hand protecting. • Actively flexing the KAFO with hand protection. • Actively Flexing without protection.
What are strength factors that need to be taken into account with KAFOs
• Patient weight • Activity level • Locking knee • Double upright vs. single upright • Material • Material thickness • Orthosis design (internal vs. external joints)
How can we accommodate for a contracture in the sagittal plane with our KAFO
• Pre-flex uprights -don't just flex the joint -flex the actual upright
What is a free knee joint? Why might you use one?
• Simple hinge • Very stable in frontal and transverse planes • Prevents hyperextension and frontal plane motion • Small compact design • Single axis- (not a lot can go wrong, can disassemble easily)
How does an electronic locking knee work? What are some benefits? downsides
• Solenoid engages lock • Audible signal to pt. • Remote control key fob (downside is you have to charge it) • Minimal upper extremity strength required • Stance control version available too
What is a fracture brace? What is it used for? What components does it use?
• Thermoplastic • Most often custom fitted (use thinner materials) • Polycentric knee joints (since they mimic anatomic) • Clamshell design • Free ankle
How can we use a thermoplastic KAFO to address genu valgum (MCL/Lateral compartment)
• Thigh - High lateral and lower medial • Calf - High medial
How can we use a thermoplastic KAFO to address genu varum (LCL/Medial compartment)
• Thigh - High medial and lower lateral • Calf - High lateral
If a patient has a coronal plane deformity at the knee what type of KAFO should we provide
• Treatment is often a KAFO with a free knee and ankle joints. -as long as the deformity is flexible
Why would you use a single upright KAFO
• Useful in genu valgum - especially bilateral • Small / light-weight patients • Use non-locking joint