Orthotics and Splints
- 1. Dr. Sanjib Kumar Das, PhDDr. Sanjib Kumar Das, PhD
- 2. Bioengineering • Bio-Engineering devices developed plays a vital role in the field of orthopedic and neurological rehabilitation. • Such devices improve function, restrict or increase support to a part of the body (like spine, lower limbs). • Bioengineering devices like orthotics are an integral part of the life of persons with disability, (especially in India, where several adults suffer from the long term effects of childhood poliomyelitis).
- 3. Orthotics • An orthosis is a mechanical device fitted to the body to maintain it in an anatomical or functional position. • The basic mechanical principle of orthotic correction is the “Three point system of Jordan.” • To remain stable, the body has to have one point of pressure opposed by two equal points of counter pressure in such a way that F1 = F2 + F3
- 4. Three point system of Jordan
- 5. Biomechanics Of Orthosis • There are four different ways in which an orthosis may modify the system of external forces and moments acting across a joint. • Control of rotational moments across a joint • Control of translational forces around a joint • Control of axial forces around a joint • Control of line of action of ground reaction force by modifying the point of application and line of action of the ground reaction force during static or dynamic weight bearing.
- 6. Classification: According to Function • Supportive: It stabilizes the joints and supports the body in its anatomical position, e.g. calipers, gaiters. • Functional: It stabilizes the joint and also makes up for a lost function, e.g. foot drop splint in common peroneal nerve palsy or dynamic cock-up splints in wrist drop. • Corrective: To correct deformities, e.g. club foot boot in congenital talipes equinovarus. • Protective: To protect a part of the body during its healing, e.g. rigid four post collar for fracture cervical vertebrae.
- 7. Classification: According to Function • Prevent substitution of function: In a full length caliper, substitution of hip flexors by abductors or adductors of hip and other similar trick movements are prevented. • Strengthen certain groups of muscles: Tenodesis splint • Relief of pain: The lumbosacral corset supports the lower back, preventing painful movement. • Prevent weight bearing: A weight relieving orthosis, prescribed for conditions like fracture calcaneum will take weight away from the injured site to a proximal site like the patellar tendon bearing area.
- 9. Regional Classification They are classified according to the anatomical area fitted with the orthosis. • Cervical Orthosis • Head-Cervical Orthosis (HCO) • Head-Cervical-Thoracic Orthosis (HCTO) • Lumbo-sacral Orthosis (LSO) • Thoraco Lumbo-sacral Orthosis (TLSO) • Upper Extremity Orthosis – Shoulder and Arm Orthosis – Elbow Orthosis – Wrist Orthosis – Hand Orthosis • Lower Extremity Orthosis – Foot Orthoses (FO) – Ankle-Foot Orthoses (AFO) – Knee-Ankle Foot Orthoses (KAFO) – Hip-Knee-Ankle-Foot Orthoses (HKAFO)
- 10. General Principles Of Orthosis 1. Use of forces: Biomechanics Of Orthosis 2. Sensation: An orthotic device often covers skin areas and decreases sensory feedback. 3. Correcting a mobile deformity: A flexible deformity (e.g. genu recurvatum or mobile scoliosis) may be corrected by an orthosis. The corrective force must be balanced by proximal and distal counter forces (three point force systems). 4. Fixed deformity: If a fixed deformity is accommodated by an orthosis, it will prevent the progression of the deformity. 5. Adjustability: Orthotic adjustability is indicated for children to accommodate their growth and for patients with progressive or resolving disorders. 6. Maintenance and cleaning: The orthosis should be simple to maintain and clean
- 11. General Principles Of Orthosis 7.Application: The design should be simple for easy donning and doffing. The more complicated the gadget the less likely it is to be accepted for permanent use. 8.Limitation of movement: Limiting motion to reduce pain, e.g. knee brace. 9.Gravity: Gravity plays an important role in upper limb orthosis, especially in those joints where the heaviest movement masses are present. For example, a Rolyan shoulder cuff (large arm sling) can be used in hemiplegia to prevent subluxation of the shoulder, which is the largest joint prone for the deleterious effects of gravity. 10.Comfort: The orthosis should be easy to wear and comfortable to use. This is possible if the forces meant for correction are distributed properly.
- 12. General Principles Of Orthosis 11.Utility: The orthosis must be useful and serve a real purpose. If one hand is functional and normal, an upper extremity orthosis for the affected side may not be used as most activities of daily living can be performed with the good hand. 12.Cosmesis: Cosmesis is important especially in the hand. A functional but unsightly orthosis is often rejected if the patient values appearance over function. 13.Duration: Use only as indicated and for as long as necessary. 14.Appropriateness: It should allow joint movement wherever appropriate.
- 13. Orthosis Used in Specific Conditions Orthosis used for nerve injury: -Radial nerve injury—a radial nerve glove is given with the wrist held in extended position or a wrist drop splint. -Ulnar nerve injury—Splints that maintain the flexion of metacarpophalangeal joints and extension at inter-phalangeal joint with a lumbrical bar, e.g. knuckle duster splint. -Median nerve injury—Splint is applied to the thumb in an abducted, opposed position. (Opponens splint).
- 14. Orthosis Used in Specific Conditions • Orthosis used for burns: Splinting done to hold the part in neutral position and this prevents stiffening of the metacarpophalangeal joints. • Orthosis used in rheumatoid arthritis: Static three point proximal interphalangeal orthosis for Boutonniere deformity. • Orthoses used for stroke and brain injury: In stroke, large arm slings are used to prevent subluxation of the shoulder.
- 15. Disadvantages of Orthosis • Lack of cosmesis: an unsightly orthosis is often the reason for a patient discontinuing its use. • Muscles supporting the spine can become weak. • Wherever segments are immobilized, we find increased movements at ends of these segments. • The person becomes psychologically dependent on it. • Reduction in bone density. • Skin ulcerations or calluses at the patient orthoses interface.
- 16. Contraindications to Orthoses • Severe deformity which cannot be accommodated in the orthosis. • If it limits movements at other normal joints. • Skin infections. • When the muscle power is inadequate to perform its function because of the weight of the orthoses. • Where the orthosis interferes grossly with clothing or limits ones style of living. • Lack of motivation or other psychological problems. • Very young or old patients.
- 17. Calipers Calipers are orthosis fitted to the lower limb. They may be • Foot orthosis (FO) • Ankle Foot orthosis (AFO) • Knee Ankle Foot orthosis (KAFO) • Hip Knee Ankle Foot orthosis (HKAFO).
- 18. Considerations While Prescribing Calipers • The stability of the hip and knee should be good before deciding how high the caliper should be. This can only be done after doing a muscle power grading, paying special attention to the hip abductors, extensors and knee extensors. • Alignment is checked whether the ankle joint is over the medial malleoli, the knee joint over the prominence of medial femoral condyle and the hip joint permits a patient to sit upright at 90°.
- 19. Foot Orthoses (FO) • The essential difference between a shoe and a boot is that a boot covers the malleoli, while a shoe does not. • The foot orthoses is nothing but a boot that has components like supports and wedges to manage different foot symptoms and deformities. • These modifications are made of various materials like rubber, foam or leather. • The FO can be divided into a lower part and an upper part
- 20. Components of the Lower Part
- 21. Components of the Lower Part • Sole: It is the part of the shoe in contact with the ground. The inner part of the sole against which the foot rests is the insole. Bars straps and wedges, which are common attachments to the foot orthoses get their leverage and attachments through the sole and exert their forces
- 22. Components of the Lower Part • Ball: Widest part of the sole that is located in the region of the metatarsal heads. • Shank: Is the narrowest part of the sole between the heel and ball. The uprights of the AFO attach themselves to a stirrup at the shank region. • Toe Spring: It is the space between the outer sole and the floor, which helps to produce a rocker effect during toe off phase of the gait cycle. • Heel: is the posterior part of the sole, which corresponds to the heel of the foot. Since it is the portion where most of the body weight is taken it needs to be resilient and thicker so that it can prevent shoe components from “wearing out” and shift weight to the fore foot.
- 23. Upper Part Components • Quarter: This is the posterior portion of the shoe upper. A high quarter is referred as a “high top” and is used by runners and footballers for greater sensory feedback, and to prevent retrocalcaneal pain. • Heel counter: In sports shoes there is a reinforcement of the quarter posteriorly called a heel counter which provides posterior stability to the shoe and supports the calcaneus. • Vamp: Vamp is the anterior portion of the upper and is often reinforced with a toe box anteriorly. In front is the tongue which protects the upper fore foot behind the lace stays. Extra-depth shoes allow more room inside the shoe for orthotic intervention.
- 24. Upper Part Components • Throat: This is the opening of the shoe located at base of the tongue, through which the foot is inserted. • Toe box: It prevents the toes from suffering trauma when the person kicks as in football. Even normally it is provided in the shoe to avoid stubbing of the toes. • Tongue: This is the part of the vamp which extends down in front of the throat. • Stirrup: This is a piece on the outer sole in the shank region just in front of the heel offering attachment to the metal uprights.
- 25. Modifications of the Orthopedic Shoe The shoe can be modified according to the deformity, disease process or congenital anatomical configuration of the patient to: • Maintain the foot in anatomical position • Treat symptoms of fatigability • Prevent further deformity • Provide symmetry • Provide a better stance and gait.
- 26. Clinical condition Objectives of modifications Modifications Limb shortening Provide symmetric posture Heel elevation: If < ½ in: internal If < ½ in: external Heel and sole elevation (if > 1 in), High quarter shoe Pes plano-valgus Reduce eversion support/ longitudinal arch Medial heel wedge, Medial longitudinal arch support, High quarter shoe. Pes equinus Provide heel strike, Reduce pressure on MT head, Contain foot in shoe Heel lift & Metatarsal pads or bars, Heel and sole elevation on other shoe depending on LLD, Wide open throat, High-quarter shoe. Pes equinovarus Realign for flexible deformity and accommodate a fixed deformity. Increase medial and posterior weight bearing on foot Lateral sole and heel wedges for flexible deformity, Medial wedges for fixed deformity, High-quarter shoe.
- 27. Clinical condition Objectives of modifications Modifications Pes cavus Distribute weight over entire foot. Reduce pain and pressure on MT Heads. Restore antero-posterior foot balance. Metatarsal pads or bars, Medial and lateral longitudinal arch, Support / Molded inner sole, High toe box, High-quarter shoe. Calcaneal spurs, calluses and corns Relieve pressure on painful area Heel cushion, Inner relief in heel and fill with soft sponge Metatarsalgia Reduce pressure on MT heads. Support transverse arch Metatarsal pad, Inner sole relief. Hallux valgus Reduce pressure on 1st MTP joint and big toe. Shift weight laterally Metatarsal pad, Soft vamp with broad ball and toe. Medial longitudinal arch support. Hammer toes Relieve pressure on painful areas, Support transverse arch. Soft vamp, extra-depth shoe with high toe box, Metatarsal pad.
- 33. Ankle Foot Orthosis (AFO) The components are: • Proximal calf band with leather straps • Medial and lateral bars articulating with medial and lateral ankle joints help in control of plantar and dorsiflexion. • Stirrups anchor the uprights to the shoe.
- 34. Ankle JointThere are five types of artificial ankle joints fit to the AFO. They are: A) Fixed ankle joint: Sometimes the foot needs to be protected and weight is taken off injured portions as in fracture calcaneus when in combination with a weight relieving orthosis it takes the weight off the foot. B) Limited ankle joint when the muscles operating the ankle have no power.
- 35. Ankle Joint C) 90° foot drop stop is when the ankle joint allows dorsiflexion but stops at the neutral position i.e. at 90 degrees. Thus it does not allow plantar flexion. It is recommended when there is foot drop i.e. DF are weak and PFs are normal, or DF are normal or near normal and PFs are spastic.
- 36. Ankle Joint D) Reverse 90° ankle joint: It allows PF but stops short at the neutral position that is at 90 degrees. Thus it does not allow DF and is prescribed to prevent a calcaneus deformity. E) Free ankle: when there is normal ankle power
- 37. Knee-Ankle-Foot Orthosis (KAFO) • It provides stability to knee, ankle and foot. • The components are the same as those in a metal AFO. • Additionally the uprights extend to the knee joint with a lower thigh band. • Thigh bands are suspension mechanisms to which the uprights are attached. They are worn by the patient to fasten the orthoses to the leg or thigh.
- 38. Knee-Ankle-Foot Orthosis (KAFO) Indications • Muscle Weakness: Weakness of the muscles of the lower limbs, commonly result from spinal cord damage or lower motor neuron disease such as poliomyelitis or injury to a nerve. • Upper Motor Neuron Lesions: Upper motor neuron lesions impair locomotor function. There is an extensor synergy in the lower limb, which is used by the hemiplegic to achieve stance stability. The orthotic device additionally incorporate knee joints, which limit hyperextension.
- 39. Knee-Ankle-Foot Orthosis (KAFO) Indications • Loss of Structural Integrity: This is due to injuries to the main ligaments of the knee or joint diseases, either due to inflammatory (septic arthritis) or degenerative (osteoarthritis) processes. The orthotic prescription is a “weight-relieving”. • Genu Varus/Valgum: The upright may be on the medial or lateral side of the leg, depending on whether it is genu varus/valgum to be controlled.
- 40. Hip-Knee-Ankle- Foot Orthosis (HKAFO) • The HKAFO is an extension of the KAFO. • Additionally there is an attached hip joint which allows hip flexion and extension only. • The suspension is with a pelvic band, extending posteriorly and laterally, which fits between iliac crest and greater trochanter and which is used to control rotational movement at the hip joint.
- 41. Hip-Knee-Ankle-Foot Orthosis (HKAFO) • In the front it is fastened with a soft Velcro or buckle strap fastener. • Movement at the hip is with an uniaxial hip joint with a drop lock, which is locked during walking. • In conditions where weight relief from the lower part of the body is needed, the body weight is taken away from the foot or leg and transmitted from ischial seat through metal uprights to the ground.
- 42. Uses of HKAFO • HKAFO provides improved posture, balance during standing and a better controlled forward leg swing in patients with weak hip muscles. • The HKAFO is prescribed whenever the muscles controlling the hip and its stability are weak. • Muscles controlling the knee and ankle may also be weak, and there may be tendency to varus or valgus of the ankle which can be accommodated in the HKAFO. Disadvantages • It is difficult to wear and remove and permits limited step length. • There is also an increase in lumbar spine movements to compensate for limited hip motion.
- 44. Dr. Sanjib Kumar Das, PhDDr. Sanjib Kumar Das, PhD
- 45. Cervical Orthosis • Cervical collars are freely available in 3 readymade sizes— small, medium and large and may be soft or hard depending on the restriction needed. Uses • Immobilization of spine helps in relieving pain. • Reminds the wearer not to move abruptly, thus prescription should only be done if the neck movement causes severe pain, giddiness or is injurious to the anatomical structures. • Long term use is to be discouraged except when severe giddiness or instability.
- 46. Cervical Orthoses/Collars(CO) Soft Collar • Made from soft foam. • Provide mechanical restraint (5-15%) and comfort. • Relief from minor muscle spasm. • Relief from cervical strain.
- 47. Head cervical orthoses (HCO) Hard collars • Semi-rigid and rigid plastics. • Provide more rigid stabilization of the cervical spine. • Include Occiput & Chin to decrease ROM. • Used in stable spine conditions. Disadvantages • Supported chin is a common place for skin breakdown. • Clavicle is area HCOs can cause skin breakdown. • Long-term use associated with decreased muscle function and dependency.
- 48. Indications for CO/HCO/HCTO • Crush injuries of cervical spine • Hyperextension injuries of cervical spine, collar is used to hold the neck in a slightly flexed position- Whiplash injuries. • Sprains or strains of the neck. • Degenerative diseases of the spine like cervical spondylosis.
- 50. Philadelphia collar • Semirigid HCO with a 2-piece system of Plastazote foam. • Plastic struts anterior & posterior used for support. • Upper portion supports lower jaw and occiput, lower portion covers upper thoracic region. • Anterior hole for a tracheostomy. • Thoracic extension can be added to increase motion restriction and treat C6-T2 injuries. Indications • Fracture of the vertebral body. • Suspected cervical trauma in unconscious patients. • Cervical strain • Anterior discectomy • Anterior cervical fusion Disadvantages • Difficult to clean.
- 51. Miami J collar • Semirigid 2-piece system made of polyethylene, with a soft, washable lining • Indications are same as Philadelphia collar • Thoracic extension can be added to increase support and treat C6-T2 injuries.
- 52. Malibu collar • Semi-rigid, 2-piece orthosis anterior opening for a tracheostomy. • Indications similar to those for the Miami J and Philadelphia collars. • Comes in only one size but adjustable in multiple planes to ensure proper fit. • Padding around the chin can be trimmed to ensure proper fit • Thoracic extension can be added to increase support and treat C6-T2 injuries.
- 53. Four Poster Cervical Orthosis (HCO) • It has padded mandibular and occipital supports attached to anterior and posterior plates by four rigid adjustable uprights. Laterally leather straps connect the mandibular and occipital supports. • Provides greater restriction of flexion, extension, lateral bending and rotation than the ordinary collar. Indication • For stable fractures
- 54. Sternal-occipital-mandibular immobilizer :SOMI (HCTO) • The SOMI is a rigid, 3-(adjustable)poster HCTO that has an anterior chest plate extending to the xiphoid process • Metal or plastic bars that curve over the shoulder. • Straps from the metal bars go over the shoulder and cross to the opposite side of the anterior plate for fixation. • Occipital piece is attached to ant. chest piece. • A removable chin piece attaches to the chest plate that can be removed during eating. • SOMI is ideal for bedridden patients because it has no posterior rods.
- 55. SOMI Indication • SOMI controls flexion in C1- C3 segments better than HCO. • Atlantoaxial instability. • Neural arch fractures of C2 (flexion causes instability).
- 56. Minerva Cast • It is a suitable modified jacket, which is applied to the head and trunk. • Anteriorly, the orthosis has a forehead strap that secures the upper posterior shell and a rigid mandibular plate. • The axillae are also covered by a wool roll. Function • This provides excellent motion limitation in all directions. • Rigid immobilization of cervical Spine Indication • Cervical spine undisplaced fracture’s • Compressed fracture of vertebral bodies
- 57. Halo Vest Immobilization • Greatest reduction in cervical mobilization. • Cranial ring secured to the skull using four metal pins. • The ring attached by four metal bars to a plastic vest and is worn continuously. • The estimated reduction in all cervical motions is 90 to 95%. • Ability to provide distracting forces aid in stabilization & reducing the load of head on the cervical spine. Function • Rigid immobilization for C1 through C8 cx spine Indication • Cervical spine injuries • Undisplaced fracture’s • Compressed fracture vertebral bodies • T.B Cervical spine
- 58. Thoraco-Lumbar-Sacral Orthosis (TLSO) These braces fix the pelvis and shoulder to prevent spinal movements in all directions. They may be classified according to whether they control flexion, flexion- extension, flexion-extension-lateral movement and all these including rotary movements. Conditions Used • Compression fracture of the vertebra. • Intervertebral disc desiccation and prolapse. • Non-operative and postoperative immobilization of spine. Uses Restriction of flexion, extension and lateral flexion of the thoracolumbar spine.
- 60. Anterior spinal hyperextension brace (ASH) • This spinal brace consists of a cross like frame anteriorly fixed with pads on the sternum and the pubic symphysis with the pads at the extremes. • Posteriorly, in addition (in the Jewett orthosis) there is a padded support in the thoraco lumbar region which maintains the spine extended by the principle of Jordan.
- 62. Milwaukee Brace• The Milwaukee brace is given for growing children with dynamic scoliosis. • It directs transverse and longitudinal forces. • The orthosis consists of a custom moulded or prefabricated plastic pelvic girdle that serves as the foundation for pelvic positioning to control the lower spine. This is accomplished by flattening of the abdomen to encourage pelvic tilt and decrease lumbar lordosis. • The anterior pelvic girdle is extended superiorly to just below the xiphoid and the ribs, providing an anterior compressive force. The remainder of the frame consists of anterior uprights leading to a neck ring. The neck ring has an anterior throat pad and two occipital pads that provide an additional longitudinal distraction force.
- 63. Milwaukee Brace • The lateral pads hold the lateral curves, but do not correct them. • The pelvic band fixes the pelvis and decreases lordosis. The collar head-band applies distracting forces that elongate the spine. • Further modifications include pads attached at various levels of the Milwaukee brace to correct other deformities of spine. • There are buckles used to distract the brace according to the height of the child. • This is thus a dynamic spinal brace that can ‘grow’ along with the children. • Conditions Used: Any lateral curvature of the spine - scoliosis and kyphoscoliosis.
- 64. Milwaukee Brace Advantages: • Can be molded or adjusted. • The average 1-year follow up showed an average 20 percent correction for thoracic curves. Disadvantages: • Must be worn for 12 to 18 months,23 hours a day. • Rejection due to psychological issues and poor acceptance by clients.
- 65. Lumbsacral Orthosis (LSO) Knight Brace: • A short spinal brace consisting of a pelvic band and a thoracic band joined by two posterior and two lateral metal uprights which, provide considerably more rigidity than a corset. Boston Brace: • Boston brace is an example of modular orthosis that provides varying control and is useful for the treatment of scoliosis. • It is made up of semi rigid plastic and supports the lower trunk by controlling all lumbosacral motion. Uses: • The orthosis reminds the wearer to avoid abrupt motion. • Motion control is achieved by means of various three-point force systems— support for the spine is also by abdominal pressure.
- 66. Lumbsacral corset (LSO) • Lumbosacral corsets may vary in rigidity based on the amount and type of metal stays included. • Longer length corsets used for more extensive spinal problems. • A corset has vertical reinforcements or a rigid posterior plate, but no rigid horizontal bands. • They are made of leather or canvas and contain elastic straps with Velcro fastening for a close fit, and available off the shelf in various sizes (28'' to 42'' waist circumference).
- 67. Lumbsacral corset (LSO) Conditions Used: Painful low back conditions associated with- • Osteoporosis • Lumbar spondylosis • Malignancy • Bad posture • Spondylolisthesis • Lumbosacral strain • Sciatica.
- 69. Splints Splint is an appliance used to support / assist /immobilize part of a body. Classification • Static Splints Static splints have no moving parts, prevent motion and are used to rest or rigidly support the splinted part. • Dynamic Splints Dynamic splints are moving splints; their parts permit, control, or strengthen movement.
- 70. General Functions of Splinting • To prevent undesirable movements. • To provide a functional position for the hand. • To promote grip and pinch. • To reduce pain. • To diminish muscle spasm. • To hold fractured bone ends in position until they are united. • To maintain the position after reduction of a dislocation until the joint capsule is healed. • To strengthen specific muscles.
- 71. Types of Splints • Aeroplane Splint The Aeroplane splint maintains the shoulder in abduction and external rotation. It immobilizes shoulder and elbow joint. It consists of chest, arm, fore arm and wrist pieces joined to one another almost at right angles. • Indications 1. Erb’s palsy. 2. Supraspinatus tendon rupture 3. Avulsion of the greater tuberosity of the humerus. 4. Tuberculous arthritis of the shoulder joint. 5. Paralysis of the deltoid muscle.
- 72. • Cock-up Splint • The cock-up splint immobilizes or stabilizes the wrist in dorsiflexion with volar or dorsal support. • It may be static or dynamic. • It allows full metacarpophalangeal flexion and carpometacarpal motion of the thumb. • The splint should be worn all the time except during exercise and bath. • Indications Wrist drop (radial nerve palsy)
- 73. • Knuckle Bender Splint Maintains the metacarpophalangeal joint in 90° flexion and interphalangeal joint in extension. • Function 1. Immobilization of fingers. 2. It provides support and stabilizes the wrist in extension. 3. It maintains the transverse palmar arch. 4. It assists in prehension. • Indication 1. Total claw hand in case of median and ulnar nerve injury, as in Hansen’s disease. 2. Ulnar claw hand.
- 74. • C-Splint This splint maintains the thumb in abduction and partial rotation under the second metacarpal and supports it. It also stretches the first web space. • Indications 1. Median nerve injury 2. Contracture 3. Burns. • Opponens Splints The opponens splint maintains thumb in abduction and partial rotation under the second metacarpal. The wrist and other fingers are free. • Functions 1. Immobilization of the thumb 2. Improves prehension by providing a stable position against which the fingers can pinch. 3. Protects the joint from pain. 4. Stretches the web space. • Indications • Low median nerve injury. • Opponens transfer (6 weeks after surgery postoperative splint). • Scaphoid fracture • Bennet’s fracture • de Quervains tenosynovitis.
- 75. Thank You Dr. Sanjib Kumar Das, MPT (Musculoskeletal), Fellow (PhD) NITIE- Ergonomics and Human Factors, Mail: sanjib_bpt@yahoo.co.in Contact No. +91 8879485847 India