SYBPO - Orthotics.This presentation consists of all the pathological reasons affecting the lower extremity causing various deformities. it consists of Cerebral Palsy, polio, CDH etc.

1. SYBPO – Orthotics
AIIPMR Lectures –
•Orthotic knee joints
•CP,Polio,CDH etc.

2. ALINGMENT OF ORTHOTIC JOINTS :
1 . HIP JOINT : Flexion – extension axis of the hip joint is coincide
with a point 6mm anterior & 6mm superior to the proximal tip
of greater trochanter so mechanical should come at this level.
2 . KNEE JOINT :As it is a polycentric joint a point where
maximum movements takes place is consider as a center .
Flexion- extension axis is at 19mm proximal to the medial tibial
plateau & at a point half the A-P diameter of knee .
3 . ANKLE JOINT :Medial malleolus is 15mm anterior to lateral
malleolus due to tibial torsion. Ankle DF & PF takes place
through the axis passing 1.5cm anterior to the tip of medial
malleolus & bisection of lateral malleolus .
Normally ankle joint axis is placed at the tip of medial malleolus

4. VARIOUS BANDS USED IN ORTHOSIS :
1 . PELVIC BAND :
It is used to control rotation & movement of the hip .
Pelvic band must lie between ASIS & greater trochanter .
This position avoids bony contact & prevent upward
displacement of brace .
Width of the PB can be increased to give more support as per
the patients need .
2 . ISCHIAL SEAT :
Ischial tuberosity is adapted for supporting body weight in
sitting position . It is required in brace when it is desirable to
eliminate the weight from extremity .
Ischium will have maximum pressure in hip extension .
As hip goes in flexion weight is shifted from ischium to
inferior ramus & pubic symphysis .

5. 3 . CALF BAND :
It is fitted on the maximum calf level & act as a one point of
the three point pressure system .
Calf band fitting is directly related with the knee joint
position .
If the knee joint axis lies above the anatomical knee joint
then there will be gap on calf in flexion & if knee joint axis is
below the anatomical joint then there will be excessive
pressure on calf in flexion .
As the knee joint placement changes pressure exerted by
bands on the body will also change .

6. In general orthopedic disorders are classified into
1 . NEUROLOGICAL ( Neuropathy ) e.g. POLIO
2 . MUSCULAR ( Myopathy ) e.g. DMD
3 . NEUROMUSCULAR e.g. . Cerebral Palsy , MMC
It is further broadly classified as :
1 . Upper Motor Neuron Lesion ( UMN )
It is a lesion at brains cortical & sub cortical region .
2 . Lower Motor Neuron Lesion ( LMN )
It is a lesion at the Anterior Horn cells of spinal cord or
motor nuclei of the brain stem .

9. BRAIN
GREY
MATTER
WHITE MATTER
MUSCLE
PYRAMIDAL TRACT
ANTERIOR HORN CELL
UMN
LMN
WWWWWW
GREY
MATTER
WHITE MATTER
Cross section of
Spinal cord

10. UMN LESION
• Lesion at brains cortical &
sub cortical region .
• Quadri , Para , hemiplegic
pattern & trunk involves .
• Spasticity / Hypertonic .
• Coordination affected
• Exaggerated tendon jerks .
• Wasting is seen in late
stage
• Movement paralysis .
LMN LESION
• Lesion at the anterior horn
cell of spinal cord or motor
nuclei of brain .
• Specific muscles or nerves
groups are paralyzed .
• Flaccidity / Hypotonic
• Coordination absent .
• Reduced tendon jerks .
• Wasting of muscle
throughout
• Muscle weakness .

11. Cognitive Dysfunction
Seizures
COMPLICATIONS OF NEURODEVELOPMENTAL DISORDERS
Motor
Dysfunction
Behavior
Dysfunction

12. Cerebral Palsy
• Cerebral palsy is a static encephalopathy
• Encephalopathy = Brain Injury that is non-
progressive disorder of posture and movement
• Variable etiologies
• Often associated with epilepsy, speech problems,
vision compromise, & cognitive dysfunction
• 150 years ago described by Dr. Little an orthopaedic
surgeon and known as Little’s Disease

13. CEREBRAL PALSY : (UPPER MOTOR NEURON LESION )
Definition :
It is a non-progressive neuro- muscular disorder of the brain which
may prenatal , natal or post natal in origin .
As it is a damage to the brain cell so electric impulses are no longer
sent to muscle cell .
Basically it is the disorder of the TONE , MOVEMENT , POSTURE &
BALANCE which may or may not be associated with perceptual
disorders , mental retardation , epilepsy ,hearing & visual
impairment .
Causes :
Prenatal : 1 . Consanguineous marriage
2 . Drugs taken during pregnancy
3 . Maternal infection
4 .Defective development of nervous system
5 . Kernicterus (damage to basal nuclei )
Fever during pregnancy is a great indication that something is wrong

14. NATAL : 1 . Birth injury
2 . Anoxaemia with cerebral anoxia
3 . Breech delivery
4 . Big babies & prolong labor
5 . Cord around the neck
POST NATAL : 1 . Infections causing meningitis
2 . Congenital jaundice
3 . Hydrocephalic baby
4 . Encephalitis (inflammation of brain )
5 . CVS i.e. Cerebro - Vascular Accidents
6 . Head injury
CP is a permanent condition & occurs approx . 1 in 400 childs
Now a days CP is slightly more common due to increased
survival of very low birth weight premature babies .

15. Primary abnormalities in CP includes :
1.Loss of selective motor control
2.Abnormal muscle tone
3.Imbalance between agonist & antagonist across joints
4.Deficient equilibrium reaction
5.Muscle weakness
LEVER ARM DYSFUNCTION :
It is a term used to describe deformities in ambulatory CP child
Five types of lever arm deformities are
1 . Short Lever Arm : Coxa Valga
2 . Flexible Lever Arm : Pes Valgus
3 . Malrotated Lever Arm : External Tibial Torsion
4 . Abnormal Pivot /Action Point : Hip Subluxation/Dislocation
5 . Positional Lever Arm Dysfunction : Erect vs. Crouch Gait

16. CLINICAL FEATURES or SIGNS : depend on site of neurological
deficit & associated defect .
1 . Delayed milestones .
2 . Head circumference is small (normal is 34 –36cm at birth)
3 . Sucking reflex absent .
4 . Drooling of saliva .
5 . Normal environmental response is absent .
6 . Abnormal reflexes .
NEUROLOGICAL CLASSIFICATION :
1 . SPASTIC PARESIS :
It is most common type which is characterised byhyper tonicity
& stiffness of muscles .
In this type part of motor cortex is replaced by areas of gliosis
& there is degeneration of pyramidal tracts .
Child shows delay in sitting , standing & walking .
Muscles resist passive movements of the joint but with pressure
can be relaxed .

17. Cerebral Palsy: Classification
•Physiologic
•Topographic
•Etiologic

18. Cerebral Palsy: Physiologic
• Athetoid
• Ataxic
• Rigid-Spastic
• Flaccid
• Mixed

19. When pressure is released spasm immediately returns .
Generally shows synergy i.e. when patient try to do one
movement another happens automatically .
Spasm & muscle imbalance leads to fixed deformity later .
2 . ATHETOID :
2nd
frequently diagnosed type . Main damage is in basal nuclei .
Fluctuating tone & dystonic involuntary movements .
Generally does not get any contractures or deformities as both
the muscle groups are equally strong . Constant , uncontrolled
motion of limb , head ,eyes interfere with coordination .
Not fitted with any orthosis as there are chances of some injury
due to involuntary movements .
3 . ATAXIA :
Least diagnosed type showing in coordination of movements &
equilibrium & poor sense of balance .
4 . MIXED : Shows all above or some features together .
5 . FLACCID : Complete paralysis of muscles .

20. Cerebral Palsy: Topographic
• Monoplegic
• Paraplegic
• Hemiplegic
• Triplegic
• Quadriplegic
• Diplegic

21. TOPOGRAPHICAL CLASSIFICATIONS :
1 . Monoplegia : one limb is involved
2 . Hemiplegia : one side of body is involved
3 . Double Hemiplegia : All four limbs are involved but one
side is more involved than other .
4 . Diplegia : Both lower extremities are involved .
5 . Triplegia : Three limbs involved .
6 . Quadriplegic : All four limbs are involved .
7 . Total body involvement : four limbs & spine involved .
Common deformities in upper limb are :
1 . Shoulder : Adductor , internal rotator & flexor tightness
2 . Elbow : Flexion contracture .
3 . Forearm : Pronator tightness .
4 . Wrist & Hand : Flexor tightness .
5 . Thumb : Adductor tightness .

22. COMMON DEFORMITIES IN LOWER LIMBS ARE :
1 . Hip : Adductor tightness .
Rectus femoris tightness .
2 .Knee : Flexion contracture .
3 . Ankle : Equinus or T.A. tightness .
4 . Foot : Rocker bottom , valgoid foot deformity .
Mainly two patterns of deformities are seen in LE .
1 . EXTERNALLY ROTATED DEFORMITIES ( ERD )
Also called as EXTENSION PATTERN
2 . INTERNALLY ROTATED DEFORMITIES (IRD )
Also called as FLEXION PATTERN

23. ERD
• Femur externally
rotated .
• Knee hyper extended .
• Tibia externally rotated
• Heel or calcaneus goes
into varus .
• Foot is supinated .
• Forefoot is adducted .
• Benefitted with
articulated AFO .
IRD
• Femur internally
rotated .
• Knee flexed & move
into valgus position .
• Tibia internally rotated
• Heel or calcaneus goes
into valgus .
• Foot is pronated .
• Forefoot is abducted .
• Benefitted with solid
ankle AFO .

24. TREATMENT PLAN IN CP :
•Complete cure in CP is impossible as brain is damage .
• Main aim is to keep patient ambulatory & independent
as far as possible .
• Up to 5 yrs of age treatment may be carried out on HEP
basis , later required complete rehabilitation .
• Physiotherapist , Occupational therapist , P & O ,
Speech therapist , Psychologist , Vocational guidance
plays important role in CP management .
• Operative treatment is given only in case of severe
contracture , as far as possible conservative method is use
• Apart from surgery PHENOL BLOCK , BOTOX can be used
to relax muscles & reduce spasticity in younger children's .

25. Orthotic criteria in CP patient depends on :
1 . Age of the children
2 . Type of CP
3 . Severity of the deformity
4 . Mental , audio , visual capacity of the patient
5 . Expectations of the family
6 . Socio-economic status
OBJECTIVES OF ORTHOSIS IN CP :
1 . To control involuntary movements
2 . To assist desire movements
3 . To prevent deformities
4 . To correct deformities
5 . Control tone ( inhibition )
6 . Improve gait pattern .

26. DIFFICULTIES IN GAIT OF CP PATIENT :
1 . Instability during stance
2 . Insufficient foot clearance during swing
3 . Problem with prepositioning of the foot at the end of
swing .
4 . Difference in stride length
5 . Increased energy consumption
ORTHOSIS :
Orthosis in CP are divided into two types :
1 . Tone control orthosis
2 . Deformity control orthosis

27. Main disadvantage is too much pressure on the medial
Longitudinal arch & depressed navicular causes discomfort
1 . FOOT ORTHOSIS : Main purpose of FO is to
1. Stabilize subtalar joint without restricting ankle movement
2 . Prevent unwanted ankle movement
3 . Assist in preferable ankle movement
4 . Give limited control of knee motion
e.g. UCBL inserts or SMO

28. UCBL support with sustentaculum tali pad :
FUNCTION :
1 . To position entire foot in neutral position .
2 . Control motion of subtalar joint .
3 . Affects rotational forces applied to the entire leg during
Stance phase .
Two three point force systems
First affects the transverse
Plane in stance phase & limit
Forefoot adduction :
1 . Medially directed force on
The shaft of 5th
MT .
2 . Laterally directed force on
Navicular bone .
3 . Medially directed force on
the lateral side of calcaneus.

29. Second force system affects the coronal plane & control
calcaneovalgus , midfoot collapsing & pronation .
1 . Medially directed force at the lateral base of calcaneus .
2 . Laterally directed force on navicular .
3 . Laterally directed force by body’s center of gravity .

30. AFO :
Functions : 1 . Assist dorsiflexion & reduces foot slap .
2 . Prevents unwanted ankle motion .
3 . Permits gradual positioning of ankle .
SOLID AFO :
Provides better
ankle stability
& better control
at knee .
Main problem is
of frequent
breakages .

31. One three point force system is present :
1.Superiorly directed force on the sole of the foot .
2.Posteriorly directed force on the dorsum of the foot .
3.Anteriorly directed force on the back of the calf .

32. ARTICULATED AFO :
In this design modification is done by providing
movement at the ankle joint .
This helps in giving more normal gait & also
Reduces breakage of orthosis compare to solid AFO

33. SPIRAL ORTHOSIS :
It is designed to absorb & use the torques that are in normal
walking .
It has limited stability at the ankle & subtalar joint .
Carbon fiber provides dorsiflexion assist & allows limited
planter flexion .

34. FRO ( FLOOR REACTION ORTHOSIS ) :
Principle : Control tendency of knee flexion by shifting
Weight line anterior to knee joint .
Encourage knee extension .
Indication : 1 . Poor quadriceps
2 . Knee instability
Design :
Consist of PSI having
ankle in 3-5 degree
of planter flexion &
anterior shell or
pretibial shell which
Covers patella .

35. Disadvantages :
1 . Heel to toe gait not possible .
2 . Hip extensor power should be good .
3 . Can not be use in case of contracture .
Modification :
Design can be
modify by
incorporating
footplate joined
by upright &
Pretibial shell

36. POSITIONING DEVICE ( NIGHT SPLINTS )
• During growth spurt muscle does not elongate with
skeletal growth & may cause deformities .
• Night bracing is required to prevent deformity when
muscles are not in use .
• Usually accompanied by exercise programme in day .
WALKING DEVICE :
•KAFO with knee joint with lock can be use as walking
device .
• In some cases KO can be used .
• HKAFO is very rarely use as pelvic band unable to
produce sufficient extension movement but only mask
the deformity .

37. Other orthosis used for CP :
1 . Foam Abduction Pillow :
It has hook & loop straps used for keeping hip in abduction .
Inexpensive & easy to replace .
Given for small child to maintain hip in abduction .

38. 2 . SWASH ORTHOSIS :
( Standing , Walking & Sitting Hip Orthosis )

39. This is designed to allow wearer for sitting , standing , crawling
or walking while keeping the hip in abduction .
It also helps in providing sitting balance & prevent scissoring
while ambulation .
Contraindicated for hip dislocation greater than 20 degree .
3 . LYCRA GARMENT (Thera Togs ):
Provide dynamic
splinting to control
abnormal tone ,
stabilize posture &
improve function .
Can be used in CP ,
MMC or any
neurological
disorder

40. 4 . STANDING FRAME ORTHOSIS :
A – FRAME ORTHOSIS :
Used for 18 months to 4 yrs. of child to provide abduction &
Internal rotation of hip .

42. POLIOMYELITIES :
• It is a lower motor neuron lesion .
• It is a virus infection of the nerve cell in anterior
grey matter of spinal cord leading to a temporary or
permanent paralysis of muscles that they activate .
PATHOLOGY : Virus gain access in the body through
nasopharynx or through gastro-intestinal tract .
It find s its way to anterior horn cell of the spinal cord
& sometimes to nerve cell in the brain stem .
If the cells are killed by virus then there is permanent
paralysis of that muscle .
If cells are damage then recovery is possible .

43. Poliomyelitis is divided into five stages :
1 .Stage of incubation :
It is a interval between infection &onset of symptoms . It last
about 2 weeks .Patient is kept on the bed rest & proper
positioning of limb is required to prevent contractures .
Night splints can be given .
2 . Stage of onset :
This last about two days & shows symptoms like INFLUENZA
i.e. body pain , headache , fever etc .
If disease does not progress beyond this stage then
recovery is possible .
3 . Stage of greatest paralysis :
It last about two months .Paralysis develop rapidly &
sometime artificial respirator may required to save life .

44. 4 . Stage of recovery :
This may continue for 2 years .
There may be complete recovery or partial recovery or none
Night splints & passive exercises are very important to
prevent deformities or tightness .
5 . Stages of residual paralysis :
Paralysis or weakness persisting after two years is
permanent & is generally associate with wasting of the
affected muscles which causes defective bone growth .
In this stage proper orthotic treatment is required for
ambulation of patient .
Orthotic management depends on extension of the disease,
availability of good muscle power & prognosis .

45. Orthosis used for PPRP are of three types :
1 . Supportive
2 . Preventive or Protective
3 . Corrective
1.SUPPORTIVE ORTHOSIS :
These are given to support weak joints in order to achieve
balance & help in ambulation .
e.g. HKAFO , KAFO , AFO etc.
2 . PREVENTIVE ORTHOSIS :
These are given to protects the weak joints & segments &
prevents further progression of deformity & also after
surgery to prevent recurrence of deformity .
e.g. Night splints , Gutter splints etc.

46. 3 . CORRECTIVE ORTHOSIS :
These orthosis helps to achieve correction by means of
active corrective mechanism ( 3 point pressure ) through
orthosis.
e .g. Pull over strap at knee & ankle
FRO to correct knee flexion
Various knee cages

47. KAFO :
FUNCTIONS :
1 . Provides stability of knee as well as ankle joints .
2 . Helps in progression of body with mobility aid .
SPECIAL CONSIDERATION :
1 . Proper alignment of knee joint w.r.t. anatomical knee .
2 . Excessive forces on bands & straps .
3 . Unnecessary structural components .
VARIOUS KAFO DESIGNS :
1 . SINGLE BAR LOCK KNEE ORTHOSIS :
2 . SCOTT CRAIG ( DOUBLE BAR KNEE LOCK ORTHOSIS ) :
Offset knee joints with pawl locks ( Swiss locks)are used
with footplates .It has one posterior thigh band & anterior
leg band so knee cap not required .
3 . LONG LEG DOUBLE BAR ORTHOSIS :

48. 1 . SINGLE BAR LOCK KNEE ORTHOSIS :
•Upright may be placed medial or lateral depending on the
deformity to be controlled .
•Generally used to control knee valgus or varus .
•For valgus lateral upright & for varus medial upright is given .
Knee lock is optional .
•One three point force system is present :
1 . Medially directed force on
Proximal thigh
2 . Laterally directed force on
Medial aspect of knee joint by
means of distal thigh band &
Calf band .
3 . Medially directed force on
Lateral side of calcaneus by the
Counter of the shoe .

49. 2 . Custom molded plastic KAFO with drop lock :
It consist of two uprights with drop lock knee joint & full knee
cap or ring lock knee with solid ankle joint or adjustable ankle
joint .
To control subtalar eversion or inversion UCBL foot insert can
be added instead of shoe .
Main function of this orthosis is to control genu valgum or
varum or hyperextension of
Knee by providing three point
Pressure system .
It is more acceptable by
patients as it is custom made
so appearance is good &
Provides better fitting .

50. 4 . QUADRILATERAL BRIM WEIGHT BEARING ORTHOSIS :
Helps to partially unload the thigh & lower limb & takes
weight on gluteal muscles .
5 . UCLA FUNCTIONAL KAFO :
Consist of plastic quadrilateral socket , Offset knee joints ,
plastic pretibial shell & hydraulic ankle joints .
Main disadvantage is hydraulic ankle joints requires more
maintenance & quadrilateral brim may add weight to
orthosis .
6 . MOLDED PLASTIC ORTHOSIS ( VAPC ) :
It has free knee joints & ankle in planter flexion . Molded
thigh shell & PSI is used . Hyper extension of knee is
prevented by high anterior thigh wall .

52. PARAPLEGIA :
It is a lower motor neuron lesion in which there is a paralysis
of lower part of body involving both legs & trunk below the
level of lesion with bladder & bowel involvement .
It is due to the injury to spinal cord in form of fracture , sever
compression , fracture dislocation or trauma .
Infection like tuberculosis , tumors , vascular diseases also
causes paraplegia .
In paraplegia motor as well as sensory loss is there so
bracing requires lot of care as patient not able to tell any
pressure or discomfort .
If the lesion is above C4 then it causes Quadriplegia &
paralysis of phrenic nerve may cause respiratory problem .
Incomplete paralysis is called as PARAPARESIS .

53. BRACING IN PARAPLEGIA :
•Main purpose of bracing in paraplegia is to stabilize
lower limbs for locomotion .
•Knee locking & foot support are main requirements
•Bracing should be as minimum as possible .
• Ischial weight bearing not permitted .
• Adequate surface area should be covered to distribute
Pressure on wider area .
•Ankle joint should prevent foot drop .
•Moderate DF of ankle should be given to have forward
Leaning on crutches & hyperextend hips .This helps in
Inclination of body & keep C.G. in front of hip .
•As upper limbs are in good condition patient can walk with
crutches either in four point gait or swing through gait .

54. DIFFERENCE IN MANAGEMENT OF POLIO & PARAPLEGIA
POLIO
• Purpose of bracing in polio
is support, protect(prevent)
& correct .
• Sensations intact .
• Ischium bears the weight .
• Shoes with closed toe box
can be used .
• Brace should be durable .
• Snug fitting can be done .
• Muscles are wasted .
• Prescription is difficult but
fitting is easy .
PARAPLEGIA
• Purpose of bracing in
paraplegic is to stabilize
lower limb for walking .
• Sensation lost so more care
required while bracing .
• No ischial weight bearing.
• Shoes with open toe box &
soft padding is must .
• Brace should be light weight
• Snug fitting not possible .
• Muscles intact .
• Prescription is easy but
fitting is difficult .

55. ORTHOTIC OPTIONS :
As skeletal is intact full weight bearing is possible but as
sensation are affected so more care is required for fitting of
orthosis .
Generally used orthosis for paraplegics are :
1 . Bil. HKAFO with HJ & lock , thigh band , KJ & lock , AJ & 90
degree FD stop & full open lacing boots & soft inner lining .
Or footplates can be given to reduce weight of orthosis .
Bands can be made up of plastic as metal requires leather
padding which may get affected with urine .
2 . Reciprocating Gait Orthosis (RGO )
3 . Pneumatic orthosis ( paraplegic suit )
4 . Para podium (standing frame )
5 . Air beds or Water beds to avoid pressure sores .
6 .Bil . Elbow crutches or walker for old age patients .

56. Reciprocating Gait Orthosis (RGO) :
Components :
1. Molded plastic pelvic band
2 . Bilateral hip joints & offset knee joints
3 . Molded posterior thigh shells
4 . Molded bilateral AFO’S with carbon fiber reinforcement in
ankle joints .
5 . Cable connecting two hip joints
FUNCTION :
•This orthosis allows reciprocal fashion of walking .
•Flexion of one hip result into extension of other by means of
cable linking two hip joints .
•Can be use for the patient having good hip flexion but weak
hip extension as in MMC case .
•As orthosis extends from spine to foot gives good support to
lower limb in paraplegic patients .

57. When patient is standing cable coupling provides hip joint
Stability & when weight shifts a step initiated & cable
coupling of the hip joint mechanism produces reciprocal
motions of the limbs .
Coupling can be released for sitting purpose .
This orthosis allows crutch less standing & dynamic stretching
of hip contractures .

58. PARAPODIUM :
It is a modular device with unique locking mechanism which
allows crutch less standing for paraplegics .
It is a prefabricated kit which has following characteristics :
1 . Stability & weight
2 . Growth adjustability
3 . Quick assembly
4 . Easy to align
5 . Easy to operate
COMPONENTS :
1 . Spring loaded shoe clamp .
2 . Aluminum uprights .
3 . Foam knee blocks & back & chest panels .
4 . Hip & knee joints with locks .
5 . Folding handles for locking & unlocking of joints .

59. Main advantage of orthosis is patient can have crutch less
Standing so can be engage in bilateral activities .
Rigidity of brace offers secure standing .
Allows patient to sit as well as to stand.

61. PNEUMATIC ORTHOSIS :
•It consist of a garment with inflatable tubes anteriorly &
posteriorly .
•When tubes are inflated they provides rigidity & when
deflated patient can bend his knees & hips .
•Available in two sizes : long & short
•Long orthosis covers hip & portion of trunk .
•Short orthosis extends 1”-1/2” below ischium .
•Toe pick up is improved by using high ankle boots or plastic
AFO’S inside the orthosis .
•Frequent checking is necessary as it may create pressure
sores in anaesthetic areas .
•Only difficulty is inflation , donning & doffing .
•Proper size should be selected & adjusted as per need .
•Repeated use for different patients is possible .

62. PARAWALKER :
It consist of bilateral KAFO with ball bearing hip joint &
Body brace to support trunk .

63. Hip joint & pelvic band as far possible is avoided in case of
paraplegics & ankle planter flexion is not given so that they
can walk with forward trunk bending & maintain their C.G.
anterior to the body & avoid the falling on back side .

64. CEREBRO-VASCULAR ACCIDENT (HEMIPLEGIA/STROKE) :
It is a upper motor neuron lesion resulting from circulatory
defect .it is a non progressive lesion affecting cortical &
subcortical region of brain .
Causes : CVA(Cerebro -Vascular Accidents ) due to Ischemia i.e.
reduce blood supply .It may be because of
1 . Hypertension
2. Diabetes
3 . High cholesterol
4 .Obesity
5 . High blood pressure
6 . Atherosclerosis i.e. narrowing of wall of blood vessel
causing friction between blood element & wall & result in less
blood supply to patient .
Increase in blood viscosity level can change tone .Vision &
speech is also affected . Commonly seen after 40 years of age .

65. Cerebro-vascular circulation (CVC) restrict due to
1 . Thrombosis : blood clot formed in arteries .
2 . Embolism : due to clot arteries break off & forms smaller clot
which causes disturbance in smaller arterioles .
3 . Haemorrhage : leakage of blood outside the arteries .
Contralateral side of the body is paralyzed .
Common deformities seen are :
U . E :Adductor tightness , Pronator tightness , Flexor tightness,
Thumb in palm , claw hand
L.E : 1. Hip adduction
2 . Knee extension
3 . Foot equinus due to T.A. tightness or contracture
Generally three stages are seen :
1.Acute Stage : last for 1-2 days , proper positioning & joint
mobilization is very important .
2. Recovery Stage : too much care & exercises required .
3 . Residual Stage : All fixed deformities may develop .

66. Treatment : 1 . Reduce Spasticity
2 . Muscle reeducation by exercises
3 . Joint mobilization to prevent contractures
4 . ADL training & Gait training
5. Proper positioning to prevent pressure sore
Orthotic Options :
1 . Night splints for proper positioning of limb .
2 . As sensations are intact fitting of orthosis is easy .
3 . As far as possible no bracing is given .
4 . If required toe pick up or AFO is given.
These all are possible when patient is in recovery stage .
If proper care in not taken in recovery stage then they may
develop fixed deformities which requires surgical intervention.

67. SPINA BIFIDA :
It is a failure of the enfolding of the nerve elements within the
spinal canal during early development of the embryo .
Folic acid is important in preventing this birth defect .
Depending on the pattern of enfolding they are classified as
1.SPINA BIFIDA OCCULTA :
•It is a minor defect in which there is a failure of fusion of
vertebral arches posteriorly mainly in lumbosacral area .
• There is no defect on the overlying skin only a dimple can be
seen on the surface .
•Neurological involvement causes muscle imbalance in lower
limb which result into foot deformity as equinovarus
•Prevention & correction of deformity is essential for
independent mobility .
•Surgical intervention may required for correcting deformity
followed by orthosis .

68. 2 .SPINA BIFIDA APERTA :
•Developmental defect involves soft tissue , skin & meninges
•Dorsolumber spine is mostly affected .
•Motor , sensory & visceral paralysis .
•Lower limb disability may be complex .
Differentiated into three types :
A . MENINGOCELE :
•Bulging sac containing meninges & cerebrospinal fluid
protrude on the skin surface .
B . MENINGO-MYLOCELE :
•Sac also contain neural element closed by membrane & skin
covering is deficient .
•Spinal cord & nerve roots are displaced posteriorly into sac.
C . RACHISCHISIS :
•Neural tube is open & exposed on the surface , cerebro -spinal
fluid leaks from the opening .

69. Objective of Bracing in MMC :
1.Improve head & neck balance .
2.Decreased pressure sores .
3.Decreased osteoporosis & stress fracture .
4.Facilitate sitting , standing & walking .
5.Reduction of joint contracture .
Management of foot deformities in MMC :
Orthotic aim in foot is to maintain the foot in plantigrade
position to make patient upright & reduce the pressure on thigh &
buttocks .
1 . Lesion above T-12 foot is generally fail .
AFO , Standing Frame , Para podium can be given .
2 . Lesion at L 3 & above : foot is equinovalgus ( positional &
gravitational deformity )
AFO , KAFO can be given .
3 . Lesion at L 4 & L 5 foot is calcanovalgus
Modified footwear , FRO can be given .

70. Some patient with low level MMC & weight bearing (walking)
patient will develop Charcot joint (Neuropathic joint) in Ankle ,
Tarsus & Knee .
CHARCOT’S JOINT :It is characterized by
•Deep pain impulses are disturb .
•Joint insensitive to pain .
•Disorganized joint articulation .
•Suffers from repeated minor injuries .
In MMC patient if Charcot joint formation takes place then as
sensitivity is lost & protective function of pain is lost , strains
are unrecognized hence lead to the severe degeneration of the
joints .
Best treatment is to provide support for the joint by a suitable
appliance or fused joint by operation .
Hygiene for the insensitive foot & care for any pressure point
is very important to have long time walking .

71. Management of Knee in MMC :
Knee is affected in all types but common in lowest spinal lesion
Main reason is muscle imbalance & malalignment at ankle joint
Common deformities of knee in MMC :
1 . Knee Flexion Contracture :
If deformity is correctable then Standing Frame , KAFO can be
given but if it is fixed deformity then surgery may required .
2 . Knee Extension Deformity ( Hyperextension of Knee) :
Modified KAFO can be given to prevent extension or quadriceps
plasty can be done to fix knee in slight flexion .
3 . Valgus or Varus deformities of Knee :
In MMC valgus is more common than varus . This can be
controlled by giving pull out or pull in strap on knee .
If deformity is very severe then derotation osteotomy can be
done .

72. Management of Hip in MMC :
Posterior stability of Hip depends on muscles of extension
innervated at S 1 .
Paralytic dislocation of hip is very common in MMC .
Lesion at L 1 – L 2 paralyzed hip flexors & displaced the hip
joint posteriorly leading to a high incidence of early
dislocation of hip .
Main purpose of rehabilitation in MMC is :
1 . Correct deformity
2 . Maintain correction
3 . Promote best possible function of affected limbs by
providing limb that is straight , mobile & with a plantigrade
foot suited for weight bearing .

74. MUSCULAR DYSTROPHY :
It is a inherited myopathy i.e. motor dysfunction due to
disease of the skeletal muscles. The defect may be due to
1 . Abnormal cellular enzymes or
2 . Abnormal structural protein or
3 . Both the reasons
If it is inherited myopathy due to abnormal structural protein
then it is called as Muscular Dystrophy.
PATHOLOGY :
•Dystrophin is a large rod like cytoskeletal protein which
connects muscle from inside .
•In absence of dystrophin as in DMD muscle membrane
vulnerable for rupture with stress & strain of normal muscle
activity.
•Defect in the membrane causes migration of Ca ions inward
causing increased intracellular Ca in muscle fibers

75. • Increased Ca overload mitochondria & breakdown the
muscle membrane .
• CPK (Creatine Phospo-Kinase) is always high in DMD cases
It is classified into :
1 . Duchene Muscular Dystrophy (DMD )
2 . Becker Muscular Dystrophy
3 . Spinal Muscular Atrophy (SMA)
4 . Limb Girdle Muscular Dystrophy (LGMD)
5 . Scapulo-Humeral Muscular Dystrophy
6 . Fascio Scapulo – Humeral Muscular Dystrophy
Usually males are affected & females are carriers of genes
Weakness starts at the age of 3-4 yrs. & progresses to the
extend where patient can not move any muscle including
respiratory muscles & finally leads to cardiac arrest .
If progress is rapid patient survives till 12-14 yrs.
If progress is slow patient survives till 40-50 yrs. as in SMA

76. CHARACTERI
STICS
DMD BECKER MD SMA LGMD FSHMD
% TAGES 1 : 3600
MALE
3 TO 6 per
1 lakh male
ONSET 2-3 Years of
age
1st
decade of
life
Early
childhood
Middle or late
childhood
WEAKNESS Proximal
more than
distal
Proximal
more than
distal
Distal
more than
proximal
Back pain &
distally more
severe
Facial
weakness
Grower Sign + ve + ve - ve - ve - ve
Heart Cardio
myopathy
Less
involved
Less
involved
unusual Deafness
common
progression rapid slow slow slow slow
Life span 18-20 yrs. 25-30 yrs. 40-50 yrs. 25 -30 yrs.
Wheelchair
bound
40-50 yrs.

77. Clinical Features :
1.Frequent fall due to muscle weakness
2.Grower sign + ve i.e. cannot get up from sitting
3.Hypertrophy of calf muscles
4.Patient walk with increased lumber lordosis
5.Absence of reflexes
6.Muscle biopsy shows hypertrophied muscle
7.EMG shows lack of contraction of muscle
8.Increase in CPK
Orthotic Treatment :
Main aim of orthosis is to prevent deformity & make patient
ambulatory as far as possible .
Night splints can be used to prevent contractures .
Light weight KAFO or Knee Orthosis are used for walking .
ADL training is required to make patient more independent .

78. Developmental Dysplasia of Hip ( DDH ) :
It is a abnormal development of Acetabulum or Head of Femur .
Orthotic goal of DDH are
1 . To attain a concentric reduction of hip
2 . To produce normal Acetabulum & Femoral Head
development .
3 . To avoid complications like stiffness , infection & avascular
necrosis of head of femur .
4 . To avoid unnecessary patient & parental hardship .
In CDH anatomical development of bones is normal but their
normal articulation with each other is lost .
Unilateral involvement in DDH or CDH is more symptomatic
than bilateral because of limb length discrepancy which leads to
the knee & back pathology .

79. Congenital Dislocation Of Hip (CDH) :
This is a spontaneous dislocation of hip occurring either
before or during birth or shortly after birth .
Causes: are either genetic or environmental .
1 . Genetical Joint Laxity :
Parents or relatives shows dislocation . It leads to lack of
stability at the hip joint .
2 . Hormonal Joint Laxity :
In female ligament relaxing hormone may be secreted by the
fetal uterus in response to estrogen & progesterone reaching
the fetal circulation. This causes instability to the joint .
This is the reason that CDH is more common in girls .
3 . Breech Malposition :
CDH is more common in breech delivery (through legs) than
normal delivery .

80. Pathology :
•Femoral head is dislocated upward & laterally from the
acetabulum .
•Neck is anteverted beyond normal angle .
•If dislocation allowed to persist development does not takes
place normally & acetabulum appears shallow .
•Labrum is folded into the acetabulum.
•Joint capsule is elongated .
•Girls are affected six times as often as boys .
•In one third of all cases both hips are affected .
•Abnormalities may not be noticed until the child walks .
•Walking is often delayed & gait is waddling or limping .
•Leg length discrepancy is seen in unilateral cases .
•Asymmetrical buttock folds are seen .
•Telescopic movement is common .
•Hip abduction is restricted in flexion position & jerk noticed

81. Treatment :
Earlier the dislocation reduced is better the prognosis .
According to the age of the patient method will change .
1 . Neonatal Cases ( 0 – 6 months) :
In most of the cases hip become stable within three weeks . If
not then bracing or casting is required for hip abduction .
2 . Age of 6 month – 6 years :
Conservative methods are used till 3 years . If problem is not
solved then operative treatment is required .Closed reduction
or rotation osteotomy is done
3 . 7 years – 10 years :
Closed reduction or open reduction or replacement
arthroplasty is needed .
4 . 11 years onwards :
Patient suffers from pain .Femoral osteotomy or total hip
replacement arthroplasty is done .

82. Orthotic Treatment :
Main aim of orthosis is to achieve reduction of the head of the
femur into the acetabulum & maintain it until hip becomes
clinically stable .
1 . PAVLIK HARNESS :
•Promotes spontaneous reduction of dislocated hip by
positioning the hip in flexion & allowing free abduction thus
minimizing the risk of avascular necrosis .
•Used during first six month of life .
•Consist of adjustable chest band , two shoulder strap which
crosses posteriorly , two ankle stirrups which contain ankle &
foot , two anterior & two posterior straps which helps to
provide desire amount of flexion & abduction of hip .
•Harness allows active movement in all direction except
extension & adduction .

84. Points to be remember during fitting of pavlik harness :
1 . Force must not be used for reduction .
2 . Position of the hip must be confirm radiographically .
3 . Hip must be flexed more than 90 degree to direct the head
into tri-radiate cartilage .
4 . Posterior straps should not be tight in order to avoid
forceful abduction . Straps should allows knee to adduct
within 1”-2 “ of the midline .
Disadvantages :
1 . Difficult to educate parents for donning & doffing of the
harness .
2 . Manual error in tightening of straps causes loss of
positioning .
3. Forceful abduction may cause avascular necrosis .
4 . Chances of inferior acetabular dislocation .
5 . Transient femoral nerve palsy may happen .

85. FREJKA PILLOW :
Soft abduction pillow designed to maintain hip in abduction
but it may develop AVN .
Von Rosen Orthosis :
It is passive restraining
Or positioning device
made up of malleable
aluminum frame
which can be
molded around
shoulder , thighs
& waist . It has very
low rate of AVN but
high rate of pressure
ulcers .

86. ILFELD ORTHOSIS :
It is a passive positioning device which hold the hips in
abduction but does not create significant hip flexion . So it is
more effective in post operative cases .
Consist of two thigh cuff & adjustable cross bar .
This is attached to a waist strap to maintain position .

87. ATLANTA SCOTTISH RITE :
It is used mainly in CDH post operatively .
Can be used for elderly ambulatory patient .
It has no extension below knee thus has no rotational control .

88. PLASTAZOTE HIP ABDUCTION ORTHOSIS :
This orthosis maintain 70 – 90 degree of hip flexion & wide
Abduction & allows free motion of the knee .
Consist of one piece pelvic & thigh bands made up of
Plastazote & separated by abduction bar .

89. LEGG – CALVE PERTHES DISEASE ( LCPD ) :
Also called as COXA PLANA or Osteochondritis of the femoral
capital epiphysis .
It is a self limited disease of the hip characterized by the
avascular necrosis of the head of the femur .
It progresses in four stages :
1 . Synovitis Stage :
In this there is a swelling of capsular shadow & soft tissue
thickening with widening of articular cartilage space .
This stage last around 1 – 3 weeks .
2 . Necrotic Stage :
Blood supply to the head of femur diminished & it undergo
degeneration loosing its original shape & size .
It last around 2 – 12 months .
3 . Regenerative Stage : blood supply starts again & new head
is reconstructed . It last around 1 – 3 year .

90. 4 . Residual Stage :
In this flattening of the head of femur & broadening of the
neck remains permanent .
CAUSES :
1 . Loss of vascularity due to fracture or dislocation of the
head of femur or neck of femur .
2 . Sometime spontaneous necrosis .
CLINICAL FEATURES :
1 . Mainly occur in children of 5 – 10 years .
2 . Usually affects only one hip .
3 . Hip movements are painful & limited .
4. Child complains pain in thigh & groin area .
5 . Limp is noticed while walking .
6 . No disturbance of general health only shortening may
persist after reconstruction of head .

91. OBJECTIVES OF ORTHOSIS IN LCPD :
Main objective of treatment are :
1 . Preserve normal femoral head & acetabular congruity .
2 . Maintain normal range of hip movement .
3 . Keep patient ambulatory while treatment progresses .
4 . To relieve pain .
More preferred orthosis is Trilateral Hip Abduction Orthosis
because it gives
1 . Dynamic maintenance of the head of femur in acetabulum
with hip in abduction & internal rotation .
2 . Eliminate the body weight from the head of femur .
COMPONENTS :
1 . ISCHIAL WEIGHT BEARING SOCKET
2 . MEDIAL SINGLE KNEE JOINT
3 . SHOE ATTACHMENT STIRRUP
4 . WALKING HEEL EXTENSION ( ROCKER )

93. Other orthotic designs are :
1 . Toronto Orthosis :
Ambulatory abduction orthosis having two thigh cuffs
attached to triangular frame which in turn attaches to
horizontal bar .

94. Hips are held in 45 degree of abduction & internal rotation of
the hip is maintain by the fixed position of the shoe on the
footplates .
Hip & knee motion allows child to ambulate with crutches .
2 . NEWINGTON ORTHOSIS :
In this knees are fixed in 10 degree of flexion .

95. New trends in orthosis for LCPD :
Generally it is observed that if patient is ambulatory with
orthosis in unilateral LCPD cases desire 45 degree of
abduction is not maintain by Trilateral orthosis or we have to
give orthosis for both limbs .
To overcome this
problem BILATERAL
HIP ABDUCTION
ORTHOSIS can be
given which will
only encompass
hip & thigh keeping
knee joint free .
For e.g. Scottish Rite

98. OSTEOPOROSIS :
It is the metabolic bone disease characterized by diffuse
reduction in bone density due to decrease in bone mass &
deterioration of bone tissue which can lead to an increase risk
of fracture .
It occurs when the rate of bone resorption exceeds the rate of
bone formation .
Two types of osteoporosis can be classified :
Type I – affects women's & is associated with estrogen
deficiency occurring 5 – 10 yrs. after menopause .
Type II – it affects male & female both & is due to calcium
deficiency & associated with aging .
Orthosis are given generally for knee are
1 . knee braces to relive the pain
2 . Braces to realign the joint &
3 . protect from pathological fractures .

99. OSTEOARTHRITIES :
OA is a degenerative joint disease due to wear & tear of joint .
Two types are recognized :
PRIMARY OA : occurs in old age in the weight bearing joints
i.e. knee & hip . It is more common .
SECONDARY OA : here degeneration of joint takes place due to
primary disease of the joint . It may take place at any age
after adolescence . E.g. OA due to CDH or due to Fractures .
Hip is generally involved in western living habits & knee is
involved in Asian living habits .
Pain & swelling are main symptoms .
Stiffness also present due to narrowing of the joint space
which limits the joint movement .
Orthosis can be used to reduce pain & realignment of the joint
Weight shift from affected side is very important .

100. RHEUMATOID ARTHRITIS :
•It is a chronic inflammation of synovial joints .
•Generally characterized by pain , swelling & limitation of
joint movements .
•In progression of disease cartilage worn out & bone surface
becomes raw .
•Joints get deformed .
•More common are MP joint of hand , PIP joint of finger ,
wrist , knee , elbow & ankle joint .
•Shows severe muscle spasm .
•In later stage joint may be dislocated or subluxated .
•Exercises along with splints are necessary to prevent
deformation & maintain the range of motion .
•Surgical intervention sometime required .

101. RICKETS :
It is a disease of the growing skeleton characterized by the
failure of normal mineralization , seen prominently at the
growth plates resulting in softening of the bones &
development of deformities .
Two types of rickets are seen :
Type I : is due to deficiency of vitamin D or defect in
metabolism.
Type II : due to deficiency of phosphate in extra cellular fluid .
Knock knees or bow legs are common deformities due to
rickets seen in walking child's in early age .
Vitamin D supplement along with calcium & phosphate is
necessary . If deformity is minor then it can be corrected
with splinting . If the deformities are sever then may required
surgical correction .

102. DEFORMITIES OF THE KNEE :
1 . GENU VALGUM ( KNOCK KNEE ) :
In this condition knees are abnormally approximated ( come
closer to each other ) & ankle are divergent ( go away ) .
Causes :
1 . Unequal growth of two sides of growth plate .
2 . Post traumatic problems .
3 . Tumours causing growth disparity .
4 . Rickets .
5 . Rheumatoid arthritis
6 . OA of the lateral compartment of knee .
Treatment :
Single bar orthosis & shoe modifications can be given to
change weight bearing pattern .
If inter malleolar distance is 10 cms & child age is above 4
yrs. then surgical correction is required .

103. GENU VARUM ( BOW LEGS ) :
In this case knees are abnormally divergent & ankles are
approximated .
Causes are same as that of genu valgum only here there is
defect on the medial side of epiphyseal plate .
Surgical correction required if the distance between two
knees is more than 8 cms .
GENU RECURVATUM ( HYPEREXTENSION OF KNEE ) :
In this knee joint goes backward beyond the neutral position
It may be congenital or acquired as in polio .
Causes :
1 . Ligament laxity
2 . Epiphyseal growth defect
3 . Mal united fractures
Usually requires braces for knee . If brace is not effective then
corrective osteotomy may required .

104. Tibial Bowing :
1.Lateral Tibial Bowing : It is normal in all .
2.Anterior Tibial Bowing :
It is associated with an absent or hypo plastic fibula .
This condition is commonly called as Fibular Hemimelia or
Postaxial Hemimelia of the limb .
Main problem in this is the shortening of the limb .
3 . Posteromedial Tibial Bowing :
It is seen in patients with Calcaneus or Calcaneovalgus foot
deformity , Triceps weakness or Extension Contracture of
Ankle .
4 . Anterolateral Tibial Bowing :
It is associated with neurofibromatosis & present in
pseudoarthrosis of tibia .

105. VARIOUS TYPES OF KNEE ORTHOSIS : KO are designed
1 . To support or control movement of knee
2 . To transfer load while allowing normal knee motion
Effectiveness of KO depends on the length of the brace .
Longer brace provides greater amount of leverage .
Three types of KO can be defined :
1 . Prophylactic Knee Orthosis :
These are usually designed with the unilateral , single hinge
system .
Used to limit the strains on medial or lateral collateral
ligaments .
2 . Functional Knee Orthosis :
These are used for post operative care or for A-P stability .
3 . Rehabilitative Knee Orthosis :
It prevents excessive load on injured part & allow early
return to activity .

106. PLUMBO ORTHOSIS ( PATTELAR CAP ) :
It consist of elastic sleeve with patella cutout & two straps
which apply dynamic tension on the patella .
It is given to prevent lateral subluxation or dislocation of
patella .
PATELLOFEMORAL ORTHOSIS :
It consist of foam padded strap that encircle the knee
immediately below the patella .
It helps to control movements of patella during flexion &
extension of knee & should be worn only during activities .

107. Elastic Knee Orthosis :
Functions:
1.Provides comfort for the patient with osteoarthritis of knee
2.Helps in minor knee sprain & mild edema .
3.Provides proprioceptive feedback .
4.Provides minimal mechanical support & retain body heat .
5.Provides compression & mild Valgus , Varus & Extension
control .

108. SWEDISH KNEE CAGE :
•It is a prefabricated device having one metal piece making
side bar & posterior popliteal band .
• Anterior thigh & calf straps are made up of heavy elastic .
•Used to prevent mild genu recurvatum while providing some
amount of M-L stability .
•Only disadvantage is that
it is cosmetically poor &
protrude out while sitting .

109. EXTENSION KNEE ORTHOSIS :
•It consist of thigh band & calf band having pivotable
adjustment & variable flexion knee joint .
•Useful in correcting knee flexion contracture by gradual
tightening knee as correction achieved .
•Mostly used postoperatively for temporary period .

110. KNEE IMMOBILIZER :
•These orthosis covers the knee all around & does not
allow any movement .
•Generally given in stable fracture cases or after surgery to
protect the part .
•Specially used when
Anterior Cruciate Ligament
is involved .
•Can be given in severe
knee deterioration
to limit the movements .

111. HINGED KNEE ORTHOSIS ( Functional Knee Orthosis ) :
•Also called as Hinged Knee Cage .
•Given to control or prevent A-P ,M-L & Rotational instability .
•Consist of polycentric
orthotic knee joints .
•Thigh shells & calf shells
•Locking mechanism may or
may not be provided .
•Protect or supports knee
against rotational instability
•Distribute the forces on the
lateral side of tibia & femur &
protect knee joint capsule .

112. MOULDED PLASTIC KNEE ORTHOSIS :
•It is custom made on positive model of patient's limb .
•Gives better fit & hence control on knee is good
•Cosmetically good .
•Recommended for mild to moderate genu recurvatum &
also for M-L stability .
•If anterior shell is added it also provides A-P stability .

113. FRACTURE BRACING :
Main objectives of fracture bracing are :
•Support the site of lesion
•Relieve the weight from site of lesion
•Maintain normal alignment of fractured part
•Maintain surgical correction
•Prevent further malalignment
Immobilization was consider as a basis to increase the rate of
calcification .
But too much of immobilization obstruct the blood supply &
may result into TAO ( Thrombo Angitis Obliterance )
Another problem is that due to constant nerve pressure some
neurological problems may occur .
Hence there was a need to mobilize the part to certain extent
with proper protection of the part .
For this purpose concept of functional bracing has come up .

114. Functions of Functional Fracture Braces :
1.Provide support for a fracture site while allowing the motion
at the joint .
2.This helps less loss of range of movement at the joint .
3.Muscle strength is not much affected due to some mobility
4.Circulation is improved .
5.Provide stimulation to the bone .
6. promotes bone healing .
7.Alignment of the body part is maintain .
Fracture management must be delayed until there is intrinsic
stability at the fracture site .

115. Functional bracing encourages union & prevents joint stiffness
by continuous use of affected limb while the fracture is kept
adequately supported by modified braces .
Closed Compartment Theory :
When part of fracture is closely protected from all sides &
supported with a snug fit appliance to resemble the natural
contours of the body to maintain the natural alignment of the
body then early ambulation is possible .
Principles of Fabrication of Fracture Orthosis :
•Fracture site should not come in weight bearing line .
•Weight should be transfer proximal to the site of lesion .
•Ground reaction should be eliminated by keeping foot hanging
& not touching the ground .
•Orthosis should provide snug fit & proper support .
•Donning & doffing should be easy .
•Light weight orthosis is preferred .

116. TIBIAL FRACTURE BRACING :
•It is the first long bone treated by orthotic device .
•Initially it is treated by below knee PTB casting .
•Same principle is used in orthosis .
•Soft tissues of the extremity are responsible for maintenance
of alignment of the bone .
•Viscoelastic nature of soft tissue exerts lateral & oblique
forces that offset the vertical load in ambulation .
•Early ambulation with orthosis helps in early union & also
reduces the complications due to non ambulation .
•Ankle joint with plastic foot insert can be incorporated which
prevents orthosis from sliding down & also avoid rotation of
orthosis .
•Tibial fracture brace are available in various sizes or it can be
custom made for individual patient .

118. FEMORAL FRACTURE BRACE :
•Fracture of middle & or proximal third of femur usually
develop varus deformity .
•Femoral bracing should be delay unless there is intrinsic
stability at the fracture site .
•There should not be any pain .
•Musculature should be good around thigh region .
•Design consist of KAFO with ischial weight bearing
quadrilateral socket with knee joint & PSI or footplate .
•Knee joint helps in mobilization during passive & active
skeletal traction .
•Gross motion may get affected due to non ambulation so
passive & active exercises with brace is important .
•Early weight bearing also helps to reduce swelling .

119. KAFO Fracture Orthosis :
Function : to provide stability for fractured long bone in the
thigh & lower leg i.e. femur fracture or tibia fracture .
•Usually knee joints are not provided in fracture brace but if
required free joints are given .
•Main feature of fracture orthosis is that it create the
hydrostatic pressure inside the circumferential shells that
surrounds the fractured bone
& extends from joint at one end
of long bone to the joint at the
Opposite end of bone .
As the shell is tightened soft
Tissue compresses & create a
Pressure which stabilizes new
Callus at the fracture site .

120. CHECKOUT OF ABOVE KNEE ORTHOSIS :
Checkout procedure provides for the systematic evaluation of
the orthosis .
Main purpose of checkout is to ascertain that orthosis is
satisfactory & to attend any modifications or adjustment that
may be required .
It consist of series of questions designed regarding fit ,
comfort function , appearance & durability of the orthosis .
It also provides convenient means of recording results of
evaluation .
Orthosis should be checked in all position in which patient
going to use it i.e. Standing , sitting & walking .
Once all above checking is done then orthosis is removed &
body part is checked to rule out any excessive pressure .

121. 1 . Is the orthosis & shoes as per the prescription ?
2 . Can patient don the orthosis without any difficulty ?
CHECK WITH THE PATIENT STANDING :
SHOE :
3 . Is the shoe fitting satisfactory & comfortable ?
Shoe should be long enough & wide to permit natural movement
of toes at the same time should not allow shifting of foot inside .
4 . Are the sole & heel of the shoe flat on the floor ?
So that body weight should be distributed on complete foot .
ANKLE :
5 . Are the mechanical ankle joint are coinciding with anatomical
ankle joints i.e. Tip of medial malleolus .
6 . Does the movement of both ankle joint is same ?
7 . Is there sufficient clearance between joint surface & body ?
8 . If varus – valgus correction strap is given then does it provide
sufficient force to correct deformity without causing discomfort?
9 . Is there minimal friction between shoe insert & shoe ?

122. 10 . Does the foot is properly placed inside the shoe insert
11 . If patient is providing marketed footwear then does it have
proper rocker action ?
12 . Does proper 5 to 7degree of toe out is provided ?
KNEE :
13 . Are the mechanical knee joints are coinciding with
anatomical knee joint ?
Generally knee joints are placed 19mm proximal to MTP .
14 . Is the knee locks are secure & easy to operate ?
UPRIGHTS :
14 . Does the uprights conform to the body contour ?
15 . Are the uprights placed along the midline of body ?
16 . Is there adequate clearance between uprights & body surface
17 . Is there satisfactory clearance between medial upright &
perineum .
18 . Is the lateral upright below the head of the trochanter but at
least 1” higher than medial upright .

123. 19 . In case of children's is there adequate provision for
lengthening
BANDS / SHELLS :
20 . Is the calf band is placed 1” below the head of fibula to
avoid pressure on peroneal nerve .
21 . Is the band is wide so that there will not be any localized
pressure on the leg .
22 . Does the band conform to the contour of the leg ?
23 . Are distal thigh band & calf band equidistant from the knee
24 . Does the ischial tuberosity rest properly on the ischial seat ?
25 . Is any flesh roll above the brim is minimal ?
26 . Is patient free from vertical pressure in the perineum area
27 . If quadrilateral brim is given then is adductor longus tendon
is properly placed in it’s channel & patient is free from pressure
in the anteromedial aspect of the brim .
28 . Is the brim of the posterior wall parallel to the ground ?

124. HIP JOINT :
29 . Is the hip joint is placed 6mm superior & anterior to G.T. ?
30 . Is the hip joint lock secure & easy to operate ?
31 . Does pelvic band fit between G.T. & ASIS following body
contour .
STABILITY :
32 . Is the patient is stable in standing ?
Malalingment of orthosis causes instability .
CHECK WITH PATIENT WALKING :
33 . Is there adequate clearance between mechanical joints &
body surface in weight bearing ?
34 . Does varus - valgus strap or shoe insert provides desired
support ?
35 . Is there any gait deviation that require attention ?
36 . Does patient walking is improved with orthosis ?
37 . Is additional strap provided to control valgus or varus of knee

125. CHECK WITH PATIENT SITTING :
38 . Can patient sit comfortably with knee flexion approx. 105
degree
39 . Are the mechanical knee joint adjustment adequate
40 . Does there any pressure on calf muscle in sitting ?
41 . Are the sole & heel of the shoe flat on the ground ?
CHECK WITH ORTHOSIS OFF THE PATIENT :
42 . Does there any irritation on skin after removal of orthosis ?
43 . Does there any pressure points because of orthosis ?
44 . Does general workmanship of the orthosis satisfactory ?
45 . Does patient consider orthosis satisfactory as to weight ,
comfort , function & appearance .