Orthotics and prosthetics for Ortho PGs 27.09.2024.pptx

Orthopaedic

1. Orthotics & Prosthetics Dr.P.Thirunavukkarasu Director and Professor, PMR Dept Govt Institute of Rehabilitation Medicine, Madras Medical College, Chennai

2. Brief Description of this lecture Orthotics and type Special conditions Cockup splint Knuckle bender splint Opponens splint Splints in Post correction of CTEV Splinting in SCI A brief note on Spinal Orthotics Ankle foot orthosis – conventional and advanced Philadelphia collar Prosthesis Types Transtibial – PTB prosthesis Trasnsfemoral – Quadrilateral socket - prosthesis

3. Definition ORTHOSIS Externally applied device used to modify the structural or functional characteristics of the neuro – Musculo – skeletal system ISO 1987 Word orthotic – Greek – meaning to correct. Orthosis - Singular Orthoses - Pleural Orthotist – Technician who fabricates the device

4. Mechanism of Action Kinesthetic Reminder – Cervical Collar – just to remind to avoid movement Restriction in ROM – Spinal Orthosis – Taylor’s brace– thereby reducing the Pain Total contact – Increase the pressure distribution and control. – Present-day thermoplastic AFO Pascal’s Law – Hydraulic mechanism – Spinal Orthosis 3-point pressure principle – Correcting the deformity – more clearly in Scoliosis correction – Milwaukee or Boston’s Brace

5. Mechanism of action Three point pressure principle – To remain stable the body has to have one point of pressure at the site of deformity opposed by two equal points of counterpressure in such a way that F 1 = F2 + F3

6. Pascal law – Hydraulic Mechanism In a hydraulic system, force applied at one point is transmitted to another using a pressurized hydraulic fluid. PASCAL’s Law LS Belt – Increasing the intraabdominal pressure increase the support to the Spinal column

7. Objectives Support Joints and soft tissues – injury Align and maintain normal biomechanics of joints – OA Splint Relieve pain – Injury Correct deformities – Milwaukee brace - Scoliosis Prevent complications – Dynamic Cock up splint – Prevent flexion contracture

8. Types For immobilization – Static – eg. Static cockup splint For mobilization Dynamic - springs allows movement of joint(s) while wearing the orthosis, so the normal muscle are kept healthy – dynamic cockup splint Static progressive – Similar principle like Illizarov – daily correcting the deformit y with a Turnbuckle orthosis Serial static -  is worn over a specific time period and is then remolded again to accommodate new changes in joint motion or positioning 

9. Nomenclature – Task force of ISPO Finger orthosis FO Hand orthosis HO Wrist Orthosis WO Wrist hand orthosis WHO Elbow orthosis EO Shoulder orthosis SO Shouder Elbow Orthosis SEO SEWHO …. Explain Naming based on the joints they cross Also specifying any design related to those joints Dynamic/static

10. Radial nerve palsy wrist drop, Thumb drop, and Finger drop (High vs low radial nerve palsy) Objectives of splint Normal length-tension relationship of muscle is to be maintained Drop posture promotes flexion contracture – to be avoided The paralysed extensor muscle gradually stretched which hinders the contractile characteristics of muscle on recovery affecting its efficiency. Again to be avoided

11. Radial nerve palsy – static vs dynamic Static splint – in early stages Dynamic splint - during late stages awaiting recovery Maintain the length-tension relationship of the extensor muscles – avoid lengthening/preventing flexor contracture To maintain the unopposed action of the Flexor muscles

12. Total claw hand and partial claw hand Intrinsic minus deformity

13. Total Claw hand Nerve involved - both median and ulnar nerve – lower level nerve palsy Muscles paralyzed - Lumbricals and Interossei Position - Intrinsic minus position Deformity - MCP Extension and IP Flexion due to overaction of Extensor Digitorum and IP flexion due to overacting FDP(DIP), and FDS (PIP) supplied by Radial and median nerve

14. Functional limitation due to claw hand In order to pick up any object there is a need to flex the MCP joint so that the patient will be able to pick up objects and will have a useful function With dorsiflexed MCP joints patient will not be able grasp the object as IP joints will not extend…

15. Ulnar nerve palsy –ulnar claw fingers Bouvier’s maneuver Dorsal pressure over the proximal phalanx to passively flex the MP joint results in the straightening of distal joints and correction of Claw deformity

16. Combined median and ulnar nerve palsy Total claw hand – Intrinsic minus deformity Knuckle Bender Splint Problems Hyperextension of MCP – countered by the Knuckle bending action of the splint Flexion of IP Joints – loss of extension is restored through the Extensor expansion by Ext digitorum

17. Role of Extensor expansion Extensor digitorum can extend middle and distal phalanges when the proximal phalanx stabilized through extensor expansion

18. Thumb opponens orthosis Short Opponens splint Osteoarthritis (OA) Rheumatoid arthritis (RA) Ulnar and radial collateral ligament (UCL and RCL) injuries. Thumb fractures Median nerve palsy Long opponens splint De quervain’s disease Scaphoid fractures EPL rupture Objective: To keep the thumb in Opposition To maintain the 1 st web space

19. Children who are walking To avoid fore foot adduction – Medial straight Border To avoid the hindfoot varus – Lateral heel wedge To reduce the tendency for Equinus – No heel Congenital talipus Equinovarus Dennis Browne splint Foot abduction orthosis During infancy Club foot boot – walking Age

20. CTEV Correction splint Present day correction splints Thermoplastic with strap Maintaining the limb in corrected position Right and left sides Ready made sizes available

21. The dynamic torsional knee ankle foot orthosis (DTKAFO). Patient wearing the DFKATO. Frontal view of the DTKAFO. 1) Helix component, 2) Midfoot hook-and-loop fastener strap C. Transverse superior view. 3) Thigh component, 4) Thigh hook-and-loop fastener strap D. Transverse inferior view. 5) Foot component, 6) Stainless steel bar. Dynamic torsional Knee ankle foot orthosis Two-year retrospective cohort results on use of a dynamic unilateral brace for treatment of clubfoot: Can compliance and prevention of recurrence both be achieved? Emily J Farrar1 , Journal of Rehabilitation and Assistive Technologies Engineering Volume 9: 1–10 © The Author(s) 2022

22. Conventional

23. Advanced modern AFO’s Posterior leaflet AFO – mild dorsiflexor paralysis Moulded AFO – Significant stability to the mediolaterally Solid AFO – In spasticity conditions Spiral AFO – Carbon material – Dorsiflexion assist

24. Other KAFO Stance control KAFO Filauer stance-control KAFO mechanical knee control mechanism E-Mag stance-control KAFO E lectromagnetic knee control mechanism Provides weight-bearing stability in stance Does not interfere with swing phase knee flexion

25. CRAIG-SCOTT KAFO A modified version of conventional KAFO lightweight and capitalize on alignment stability Maximal stability in standing with a KAFO is achieved with Ankle positioned in neutral or dorsiflexion, Knees locked in extension Hips passively positioned in extension Rigid Anterior tibial and posterior thigh band Cross bar added to metatarsal head area for mediolateral stabilization Off set knee joint with bail lock Indications: complete lesion at L1 or higher paraplegia for ambulation . Parastance

26. FUNCTIONAL EXPECTATION IN PARAPLEGIA PATIENTS Level of injury Mobility T2-T10- Stands with braces for exercise Independent in transfers and wheelchair mobility T12 Functional mobility start L2 Potential for swing to gait with long leg braces indoor use of forearm crutches L3- potential for community ambulation with short leg brace L4-L5 Potential for ambulation without assistive device

27. ORTHOSIS AT DIFFERENT LEVEL OF INJURY T2-T10- Reason for failure to achieve functional gait loss of trunk and pelvic control loss of proprioception at lower extremity spasticity difficulty in maintaining balance Orthosi -B/L KAFO-with crutches and walker, used for standing balance T12 - Abdominal and back muscles are intact. Hip may or may not have proprioception B/L KAFO/HGO/RGO/ARGO crutches or walker

28. L1-L2- Hip flexors and adductors are present and hip joint proprioception is normal B/L KAFO with forearm crutches L3-L4 -quadriceps id good,weak abductor and knee proprioception normal ankle muscle and proprioception may be weak or absent. AFO set in 5-10 degree DF with elbow crutches L5 &ABOVE - AFO with or without crutches. crutches can be removed when the abductor reach power grade 3+

29. Metallic HKAFO Thermoplastic HKAFO Hip Guidance orthosis RGO – Reciprocating gait orthosis Studies about orthosis in paraplegia Functional mobility in a wheelchair is more efficient than walking with braces Robb et al. followed 22 patients with L3–4 and above para who were randomly prescribed either an RGO or an HGO. At 1 year, regardless of type of orthotic assigned, no drop out from orthosis, At follow-up of all participants at 5 years, orthosis used dropped to 45%, and after another 5 years was 23%

30. Floor reaction Orthoses Mechanism Newton’s third law - for every action there is equal and opposite reaction Body weight over the orthosis and over the ground – force to ground Resultant Ground reaction force from the floor or ground This resultant GRF is appropriately redirected to control the limb and obtain the desired outcome

31. Floor reaction orthosis Components Posterior shell like a solid AFO – good ankle stability Toe plate is stiff and long with slight plantar flexion – Always keep the external moment in front of knee avoiding buckling Anterior shell comfortably capture the resultant extension moment and stabilizes the knee.

32. FRO Indications Postpolioresidual paralysis – where the quadriceps is weak with good hip extensors Crouch gait in Cerebral palsy - excessive dorsiflexion with increased knee flexion and increased hip flexion in mid stance Contraindications for FRO Fixed contracture of knee and ankle Bilaterally not possible Hip flexion contracture is if more than 30 Degrees

33. NOMENCLATURE Name by the body regions that they cross/ Eponyms CO : Cervical Orthosis Soft or rigid (Philadelphia, Aspen Collar, Miami J, Newport) CTO : Cervicothoracic orthosis Halo, SOMI, Minerva CTLSO : Cervicothoracolumbosacral orthosis Milwaukee TLSO : Thoracolumbosacral orthosis Custom-fabricated body jacket, CASH, Jewett, Taylor and Knight-Taylor LSO : Lumbosacral orthosis Soft and rigid Corsets/Binders, Chairback, Williams brace SO : Sacral orthosis Trochanteric belt, sacral belt, sacral corset

34. Prosthesis End-bearing prosthesis- load bearing through the end of the stump to the prosthesis – Articular cartilage characteristics of load sharing. Syme amputation Through knee amputation Proximal weight bearing Transtibial amputation – Patellar tendon bearing prosthesis Transfemoral Amputation – Ischial seat weight bearing.

35. PTB prosthesis – transtibial amputation Patellar tendon bearing prosthesis It is proximal weight bearing. Components are Foot ankle assembly Shank piece Socket component Suspension of the prosthesis

36. Types of foots SACH foot Solid ankle cushion heel foot Need to wear shoes – barefoot walking not possible Jaipur foot – Dr.P.C.Sethi of Jaipur 3 Part vulcanized rubber Barefoot walking – fire and water resistant

37. Energy storing feet Providing dynamic push off Have elastic keel structures that absorb energy during midstance and terminal stance while the patient is running and then "release" it during pre-swing and initial swing Indicated in athletes Expensive and less durable Oscar Pistorius – Blade runner

38. Uniaxial foot – Single axis foot provides DF & PF movement more functional than SACH Foot heavier and less durable than SACH foot More used in Transfemoral amputations than Transtibial amputations.

39. Multi – axis foot Allows DF, PF, Inversion, Eversion, and transverse rotation Better walking on uneven grounds. Has good shock-absorbing capacity But, heavier, less durable, and more costly than the conventional SACH Foot Ex – Endolite Multiflex foot.

40. Major Concerns for Socket Design Patellar tendon bearing (PTB) transtibial socket – hard rigid socket Triangular in cross-section Major weight-bearing areas – should be able to bear the weight Patellar bar – principally bears the weigh t

41. Posterior Tissue Posterior Lateral Anterior Patella Tendon Interosseous Groove Medial Shaft Tibial tuberosity Fibular head Fibular end Mid of Fibula Harmstring Tendon Principles of weight transfer Relief pressures on Pressure Intolerant Area of residual limb to prevent pain or injure. Apply forces on Pressure Tolerant Areas to hold the prosthesis firmly on the residual limb. The shape of a prosthetic socket should be different from residual limb shape

42. Weight transfer principles… Pressure sensitive Tibial crest, tubercle and condyles Fibular head Distal tibia and fibula Hamstring tendons Pressure tolerant Patellar tendon Pretibial muscles Gastrocnemius – soleus muscle Popliteal fossa Lateral flat aspect of fibula Medial tibial flare

43. Shank piece There are two types of prosthesis Exoskeletal - Crustacean Endoskeletal - Modular

44. Exo and Endo skeletal prosthesis Exoskeletal Hard outer plastic shell With hallow wooden shank piece Does not allow alignment changes in the finished prosthesis Simple, heavy, less costly Less cosmetic appearance Useful in field work and can be fitted with Jaipur foot

45. Exo Vs Endo Endoskeletal Connected to the foot component with a pylon Allows for alignment changes after finish and easy component change Pylon is covered with contoured polyurethane foam with a soft feel Light weight, costly but more cosmetic appearance Difficult to use in Rainy seasons..

46. Suspension – during swing phase Supracondylar cuff a strap fitted just above the femoral condyles – most common Elastic stockinette type suction suspension

47. Energy expenditure Gait velocity reduced by 11% Oxygen consumption increased by 7% Non vascular as cause for amputation Gait velocity is decreased by 44% Oxygen consumption is increased by 33% For vascular as cause of amputation

48. Transfemoral amputee Ideal stump Length – 8.5 to 13.6 cm - minimum Non end bearing stump – proximal weight bearing in the ischial seat Other features of ideal stump

49. Prosthetic prescription Foot ankle assembly Shanks – exo or endoskeletal Knee units Sockets Suspension system

50. Knee Units Mechanical Fluid controlled

51. Mechanical Knee unit Simple caliper knee joint with drop lock manual locking – during walking Unlocking manually – during sitting Useful in elderly amputees Constant friction single-axis knee Uniaxial – flexion and extension movement Good stability cadence non – responsive – the unit can be set for only one uniform speed – patient can’t walk at varying speeds Require good hip extensors to prevent knee buckling. Four bar Polycentric Knee –used in through knee disarticulation – used for very long stumps

52. Fluid control knee units Fluid control knee units Cadence responsive knee units. Can vary the speed of gait Hydraulic Pneumatic

53. Hydraulic Unit Can support heavier and more athletic knee Knee velocity is controlled in both swing and stance phases , able to give gradual resistance to knee flexion in the late stance phase

54. Pneumatic unit Air filled units and lighter in weight Predominantly controls knee velocity during the swing phase Cannot support the heavier or more athletic knee

55. Microprocessor controlled knee Intelligent knee Automatically adjusts hydraulic damping in the knee so that the swing of the prosthesis matches the individual user’s walking speeds. wearers comment that they no longer have to think about changes in their walking speeds – their knee does it for them. Ottoback C leg

56. Quadrilateral Socket For ideal AK stump Has a flat horizontal posterior shelf on which the ischial tuberosity and gluteal muscles rest. Inward femoral triangle bulge anteriorly – to keep the ischial tuberosity on the postr shelf, with a channel for Rectus femoris tendon Medially there is anterior channel for Add.Longus Laterally it covers over the Greater trochanter. Wide mediolateral and narrow antero-posterior

57. Ischial containment socket Normal shape Normal alignment – NSNA Socket – by CAT CAM method (contoured adducted trochanteric – controlled alignment method Postr wall is about 1 inch proximal to ischial level and is contoured to support Ischium and gluteal muscles Gives mediolateral control more, and has a less mediolateral width than antrpostr width Provides more energy efficient ambulation at high speeds Useful for short stump Useful for weaker gluteus medius muscle

58. Sockets in AK prosthesis

59. Suspension systems Silesian band – routinely used Suction suspension system

60. Suction suspension system silicone liner or nylon stocking over the stump Valve lets air out of the socket as pulled over stump Negative atmosphere (vacuum) is created which keeps the socket on close fit between stump and socket needed

61. Advantages - suction greater freedom of movement increased use of the remaining muscles decreased pistoning (motion of stump inside socket) less perspiration, better cosmesis increased comfort due to elimination of belts and straps

62. Gait analysis Traumatic amputees Gait velocity decreased by 35 % Oxygen consumption is increased by 33% Compared to normal individuals

63. Thank you