Ovid: Pediatrics

Editors: Tornetta, Paul; Einhorn, Thomas A.; Cramer, Kathryn E.; Scherl, Susan A.
Title: Pediatrics, 1st Edition
> Table of Contents > Section III: – Specialty Clinics > 22 – EQUIPMENT

Clifford L. Craig
Nicole Parent
Mark D. Clary
Robert N. Hensinger
A wheelchair is a type of mobility system. The following
questions need to be considered when writing the prescription for a
child who will need to use a wheelchair:
  • How long will the child be in the chair each day?
  • Will this be the child’s primary means of mobility?
  • Are there any fixed deformities of the trunk or lower extremities?
  • Does the child have head and trunk control?
  • What are the child’s activities?
  • What are the environmental requirements?
Writing the Prescription
Assistance of a knowledgeable physical or occupational
therapist is essential. Include diagnosis, duration of need, and
justification for type of chair, and each component or accessory. Table 22-1 details the many variables of wheelchairs.
  • Type: frame and weight
  • Back
    • □ Height: need to support mid-back
    • □ Fixed/reclining
  • Components and accessories
    • □ Foot rests
    • □ Seat/cushion: abduction wedge; air, gel, or foam
    • □ Trochanter pads/hip guides
    • □ Scoliosis pads
  • Control straps
    • □ Seat belt
    • □ “H” straps: kyphosis
    • □ Pelvic belt: controls sacral sitting
  • Tray
Assistive devices enlarge the base of support in stance
and swing phase of gait, enhance balance, and decrease the
weightbearing load.
  • Crutches
    • □ Axillary
    • □ Forearm (Lofstrand/Canadian)
    • □ Platform
  • Canes
    • □ C-handle
    • □ Four-pronged base
    • □ Hemiwalker
  • Walkers
    • □ Standard
    • □ Folding: portable
    • □ Reciprocating: articulated, each arm can move independently
    • □ Rolling: wheeled—front, back, both
    • □ Platform: forearm support
    • □ Posterior: positioned behind the patient; promotes erect posture (sometimes called a Kaye walker)
Prescribing a prosthesis for a child is particularly
challenging given the dynamics of growth, activity level, and variable
motor coordination.
  • Provide components appropriate to the child’s age and level of gross and fine motor function.
  • Function should be a priority over cosmesis.
  • Initial lower limb prosthesis fitted when starting to pull to stand (7 to 9 months)
  • Initial upper limb prosthesis fitted when starting twohanded activities (6 to 9 months)
Prescription Considerations
  • Suspension: belt versus socket
  • Activity level: influences suspension, structural strength needed
  • Structure
    • □ Endoskeletal: modular components with a soft cover
    • P.241
    • □ Exoskeletal: wood or polyurethane covered by plastic laminate; more durable






22 lb


30 lb


40 lb



More portable






Solid plastic






Hand rims

One-arm drive

For hemiplegics—where the user grips to propel the wheels

Quad projections

Rubber extensions for improved leverage

Wheel locks


Brake extensions

Positioned at front of seat for ease of access

Back frame


Changes orientation by seat to back and knee angles


Changes orientation of seat and redistributes pressure but maintains angle at hips, knees, and ankles

Head rest/collars

Support based on head and neck control

Hensinger collar

Circumferential collar

Arm rests


Tubular swing-away

Foot rests


Built into frame


Can be moved to facilitate transfers


Foot plates

Single or two piece

Heel and toe loops

Help center foot on footrest

Lower Extremity Prostheses
Developmental Staging
  • Birth to 6 months: usually not fitted
  • 7 to 14 months
    • □ Foot: foam filling in shoe
    • □ Solid tube connecting foot to socket
    • □ Hip joint for sitting if needed
    • □ Omit knee joint
  • 15 to 36 months
    • □ Consider articulated knee
    • □ Tube extension for growth
  • 37 to 72 months: add solid ankle cushion heel (SACH) foot or articulated knee
  • 7 to 12 years
    • □ Consider hydraulic polycentric knee
    • □ Depends on height and weight and muscle control
  • 12 years to adulthood: transition to adult prosthesis
Amputation-Level Considerations
  • Hip disarticulation
    • □ Socket
      • □ Extends to waist
      • □ Enclose contralateral side for suspension
      • □ Single-axis hip joint
      • □ Endoskeletal structure
      • □ Knee locked initially
  • Transfemoral
    • □ Socket
      • □ Ischial containment variations
      • □ Adducts femur and locks ischial tuberosity
  • Suspension
    • □ Silesian belt initially
    • □ Silicone socket at 2 to 3 years
    • □ Suction socket at maturity
  • Transtibial
    • □ Socket
      • □ Patellar tendon bearing (PTB)
      • □ Supracondylar suprapatellar (SCSP)
      • □ Supracondylar (SC): patella-free
    • □ Suspension
      • □ SC cuff
      • □ Silicone suspension liners
  • Ankle disarticulation (Symes)
    • □ Socket: extends to patellar tendon
      • □ Obturator (medial opening) design
      • □ Silicone bladder prosthesis
  • Partial foot
    • □ Lange silicone partial foot prosthesis
      • □ Cosmetic foot shell
      • □ Silicone-laminated socket
      • □ Posterior zipper
  • Prosthetic feet
    • □ SACH
      • □ No articulations
      • □ Motion depends on compression of material in foot
    • □ Single axis: allows passive sagittal motion
    • P.242
    • □ Multiaxis: allows sagittal and coronal motion
    • □ Dynamic response
      • □ Energy storing
      • □ Spring mechanism in heel
      • □ Preferred for feet more than 12 cm in length
Upper Extremity Prostheses
Control Systems
  • Body powered
    • □ Shoulder movement activates terminal device
    • □ Grip strength from rubber bands
    • □ Bulky harness
    • □ Terminal device: hand or hook
  • Externally powered
    • □ Switch or myoelectric control
    • □ No harness
    • □ Muscle in limb controls terminal device
    • □ Heavy; difficult to use in children under 2 years
    • □ Grip strength built into system
    • □ Terminal device: hand only


Stands for



Lower limb


Foot orthosis


Ankle-foot orthosis

Solid, articulated, PLS, conventional (metal); custom molded or prefabricated


Knee-ankle-foot orthosis

Single or double upright


Hip-knee-ankle-foot orthosis

May be bilateral or unilateral


Reciprocating gait orthosis

Type of HKAFO; allows hip flexion in swing, stability in stance


Supramalleolar orthosis

Controls subtalar motion, allows limited plantarflexion and dorsiflexion


University of California, Berkeley, Laboratory orthosis

Orthosis was designed there; addresses flexible hindfoot deformity


Single-action adjustable joint

One channel only


Double-action adjustable joint

Two channels for control of dorsiflexion and plantarflexion (assist and stops)

Upper limb


Hand orthosis

Does not extend or control wrist


Wrist-hand orthosis

May or may not have thumb spica


Elbow orthosis

May be protective or stretching


Elbow-wrist-hand orthosis

Extends over wrist in addition to elbow


Shoulder-elbow-wrist-hand orthosis



Cervical orthosis

Cervical collar


Cervicothoracic orthosis

Minerva or Somi


Sternal occipital mandibular immobilizer

Type of CTO


Lumbosacral orthosis

Addresses injuries L1-L5


Thoracolumbosacral orthosis

Addresses injuries T4-L5


Cervicothoracolumbosacral orthosis

Cervical extension for injuries above T4 in addition to other thoracic or lumbar injury




Patellar tendon bearing




Supracondylar suprapatellar



Solid ankle cushion heel

Used for prosthetic feet


Off the shelf

Not custom molded

Terminal Devices
  • Hands and hooks
    • □ Body or external power
    • □ Voluntary open and closing
Congenital Below-Elbow Amputation
  • Most common congenital upper extremity deficiency
  • Most ideal for prosthetic fitting
    • □ Initial fit at 6 to 15 months: passive hand
    • □ 15 to 18 months reaching begins: start body- or external-powered prostheses.
The goal of an orthosis is to control motion, correct or accommodate deformity, and compensate weakness. Table 22-2 lists the acronyms that refer to orthoses, Table 22-3 describes joint motion control options, and Box 22-1 highlights


the elements that must be included in a prescription for an orthosis.





No restriction in plane of motion, with medial and lateral stability


Spring added to increase range and velocity


Spring added to decrease range and velocity


Blocks all motion or limits to a specific range


Mechanism to block motion when engaged

Lower Extremity Orthoses
  • Postoperative shoes
    • □ Hard sole (wooden)
    • □ Velcro closure
    • □ Open toe
  • Extra-depth shoes
    • □ 1/3-inch longer, ½-inch wider than standard size shoe
    • □ Removable inner sole to accommodate orthosis
  • Custom-molded shoes
    • □ Made from cast of foot
    • □ Accommodates severe rigid deformity
  • Corrective shoes
    • □ Reverse last open-toe prewalker shoes—forefoot abducted
    • □ Reverse last closed-toe shoes (ambulatory)—forefoot abducted
    • □ Straight last open-toe prewalker shoes—forefoot neutral
    • □ Straight last closed-toe shoes (ambulatory)—forefoot neutral
  • Shoe modifications
    • □ Heel
      • □ Thomas heel: additional medial support to control pronation
      • □ Medial wedge: controls midfoot and hindfoot pronation
      • □ Lateral wedge: controls midfoot and hindfoot supination
    • □ Sole
      • □ Medial sole wedge: controls forefoot eversion
      • □ Lateral sole wedge: controls forefoot inversion
      • □ Metatarsal bar: decreases pressure on metatarsal heads
  • Denis Browne bar (foot abduction bar) (Fig. 22-1)
    • □ Attaches to reverse last or straight last shoes
    • □ Positions feet in adjustable amounts of external rotation
    • □ Able to set separate amounts of external rotation for unilateral applications
    • □ Width of bar should equal width of child’s shoulders
Figure 22-1 Denis Browne bar (attached to reverse-last shoes)
Foot Orthosis
  • Accommodative
    • □ Soft materials
    • □ Custom molded or off-the-shelf (OTS)
  • Semi-rigid
    • □ Multidensity layered materials
    • □ Custom molded or OTS
  • Corrective
    • □ Rigid materials
    • □ Used for flexible deformities
    • □ Custom molded or OTS
Additional foot orthosis prescription criteria are based on individual control requirements.
  • Medial wedge: controls pronation and heel valgus
  • Lateral wedge: controls supination and heel varus
  • Longitudinal arch support: controls pronation and heel valgus
  • Metatarsal pad: pressure relieves metatarsal head, placed proximal to metatarsal heads
University of California, Berkeley, Laboratory (UCBL) Orthosis (Fig. 22-2)
  • Plastic molded insert named for origin of development (UCBL)
  • Controls flexible hindfoot deformity
  • Accommodates rigid deformity and prevents progression of deformity
  • Extended medial wall to control forefoot adduction
  • Extended lateral wall to control forefoot abduction

Figure 22-2 University of California, Berkeley, Laboratory (UCBL) orthosis.
Lace-Up Ankle Orthosis
  • Canvas orthosis with lace-up anterior support and medial and lateral corrective straps to control inversion, eversion, or both
  • Fits in athletic shoe
Ankle Stirrup
  • Restricts inversion and eversion (coronal plane motion)
  • Allows free dorsiflexion and plantarflexion (sagittal plane motion)
  • Fits in athletic shoe
Cast Boot
  • Prefabricated ankle immobilizer
  • Immobilizes ankle but allows knee flexion
  • Smallest size: accommodates 6-inch foot length
Supramalleolar Orthosis (SMO) (Fig. 22-3)
  • Molded or prefabricated plastic orthosis that extends above malleoli
  • Allows limited plantarflexion and dorsiflexion, restricts inversion and eversion
  • Controls pronation and supination, forefoot motion
Ankle-Foot Orthosis (AFO)
  • AFOs can be custom molded or fit from prefabricated design components.
  • Solid ankle (Fig. 22-4): restricts sagittal and coronal plane motion
  • Articulated ankle
    • □ Provides controlled motion at the ankle
    • □ Limited or assisted motion (plantarflexion and dorsiflexion)
    • □ Dorsiflexion stop: check strap or pin in anterior channel of metal joint
    • □ Plantarflexion stop: plastic stop or pin in posterior channel of metal joint
    • □ Dorsiflexion assist: assist joint or spring in metal joint
    • □ Plantarflexion assist: assist joint or spring in metal joint
    • □ Free motion: free dorsiflexion and plantarflexion with restricted subtalar motion
  • Dorsiflexion assist
    • □ Nonarticulated
      • □ Posterior leaf spring design
      • □ Plastic trimmed posterior to malleoli
      • □ Low-profile design
      • □ Restricts plantarflexion and allows limited dorsiflexion
    • □ Articulated (Fig. 22-5)
      • □ Jointed with dorsiflexion spring assist
      • □ Limits inversion and eversion
      • □ Resists plantarflexion but allows range of motion
      • □ Allows free assisted dorsiflexion
  • P.245
  • Patellar tendon bearing (Fig. 22-6)
    • □ Modifications done to positive cast to lessen weight on lower extremity
    • □ May include solid or articulated ankle
  • Conventional metal (Fig. 22-7)
    • □ Can be rigidly attached to shoe with metal stirrup
    • □ Can be fit inside shoe with plastic insert attached to metal stirrup
    • □ Double upright: increased stability and rigidity, heavier person, more adjustability
    • □ Single upright: smaller lever arm (shorter leg), less rigidity
    • □ Single-action adjustable joint (SAAJ): dorsiflexion assist or stop
    • □ Double-action adjustable joint (DAAJ): dorsiflexion and plantarflexion assist and stop
Additional AFO prescription criteria based on individual control requirements:
  • Extended medial wall to control forefoot adduction
  • Extended lateral wall to control forefoot abduction (Fig. 22-8)
  • Toe sulcus length footplate to allow metatarsal phalangeal (MTP) extension
  • Full-length footplate to protect toes and allow for growth
  • Tone-reducing footplate to apply contact and stimulation to decrease hypertonicity or spasticity
  • Total contact: includes anterior shell (clamshell design)
  • Sustentacular tali or longitudinal arch pads to control pronation
  • Eversion and inversion control straps
  • Lateral flanges to control supination and inversion
  • Medial flanges to control pronation and eversion
Figure 22-3 Supramalleolar orthosis.
Figure 22-4 Solid ankle-foot orthosis.
Figure 22-5 Articulated ankle-foot orthosis.
Figure 22-6 Patellar tendon-bearing orthosis.
Figure 22-7 Conventional metal ankle-foot orthosis.
Figure 22-8 Extended lateral wall-forefoot abduction control.
Knee-Ankle-Foot Orthosis (KAFO)
KAFOs can be custom molded or assembled from
prefabricated components based on a series of measurements. Support is
provided to the knee, ankle, and foot. Parameters for control needed at
each joint must be provided on the prescription.
  • Foot control options
    • □ Full-length footplate
    • □ Sulcus-length footplate
    • □ Tone-reducing footplate
    • □ See additional foot orthosis prescription criteria based on individual control requirements (described earlier).
  • Ankle control options
    • Solid ankle
    • Articulated ankle
      • □ Dorsiflexion or plantarflexion assist
      • □ Dorsiflexion or plantarflexion stop
      • □ Free motion
    • Conventional metal
    • See additional AFO prescription criteria based on individual control requirements (described earlier)
  • Knee control options
    • Drop lock
      • Engaged locks in full extension
      • Disengaged allows free flexion
    • P.246
    • Adjustable extension
      • Allows knee to lock in position other than full extension
      • Combined with drop lock will allow full flexion when lock disengaged
    • Posterior offset: allows extension movement to prevent knee flexion (buckling) without need for manual drop lock
    • Bail lock
      • Locks in full extension
      • Releases into flexion with lever located behind the knee
    • Static progressive
      • Allows incremental increases in range of motion
      • No motion, locks at position set, used for stretching or contracture management
    • Single upright (Fig. 22-9) or double upright (Fig. 22-10)
Figure 22-9 Single metal upright ankle-foot orthosis.
Hip-Knee-Ankle-Foot Orthosis (HKAFO) (Fig. 22-11)
HKAFOs provide motion control to the hip, knee, ankle,
and foot. They are generally custom molded but can be assembled from
measurements using prefabricated components. Parameters for control
required or range of motion to be limited/allowed must be specified on
the completed prescription for each joint included. They may be
unilateral or bilateral.
Figure 22-10 Double metal upright knee-ankle-foot orthosis.
Figure 22-11 Hip-knee-ankle-foot orthosis.
  • For foot, ankle, and knee options, see previous section on knee-ankle-foot orthosis.
  • Hip control options
    • □ Drop locks
      • □ Lock in full extension
      • □ Free flexion when unlocked
    • □ Adjustable extension
      • □ Lock in set amount of flexion or extension
      • □ Used with drop lock generally
    • □ External and internal rotation control: twister cable from knee to hip joint or offset in metal upright
    • □ Abduction and adduction control: allows range of motion between set parameters or locked at abducted position
    • □ Hip control provided with pelvic band
      (molded or prefabricated) or extended thoracic support (molded or
      prefabricated) for additional trunk control
Standing Frame (Parapodium) (Fig. 22-12)
  • Adds component of thoracic stability to HKAFO
  • Can be used with or without HKAFO system
  • Some models flex at knee, allow swivel walking (limited mobility)
Twister Cables
  • Reverse-wound cables attached to pelvic band to provide external or internal rotation assist.
  • Can be attached to HKAFO or AFO system
  • Can be used unilaterally or bilaterally

Figure 22-12 Standing frame (parapodium).
Upper Extremity Orthoses
Wrist-Hand Orthosis (WHO)
  • Custom molded (Fig. 22-13)
    • □ May include anterior shell for total contact
    • □ Impact protection for postfracture healing
    • □ Allows metacarpal phalangeal (MP) flexion to 90 degrees, should not extend past palmar crease
    • □ Allows elbow flexion, should end distal to bicipital crease
    • □ May include thumb spica
  • Prefabricated
    • □ Elastic or neoprene
    • □ Aluminum palmar or dorsal support (aluminum stay)
    • □ Limited motion control and impact protection
    • □ May include thumb spica
Figure 22-13 Molded wrist-hand orthosis.
Neoprene Wrist-Hand Orthosis, Neoprene Hand Orthosis
  • Ventilated neoprene material
  • Measured or used prefabricated
  • Used to maintain wrist in extension or thumb abducted
Elbow Orthosis (EO) and Elbow-Wrist-Hand Orthosis (EWHO) (Fig. 22-14)
  • Provides varus and valgus control at elbow
  • Usually custom molded
  • Provides total contact, free or limited range of motion at elbow
  • Sarmiento design for fracture management of distal humeral fractures
Shoulder-Elbow (Sarmiento) Orthosis
  • Fracture management of proximal-third humeral fracture
  • Includes thoracic stability strap to decrease rotation of orthosis
  • Trimmed distally to allow elbow flexion
Midshaft Humeral (Sarmiento) Orthosis
  • Midshaft humeral fractures: total contact design
  • Can be custom molded or prefabricated (smaller patients custom molded)
Shoulder Abduction Orthosis
  • Controls and limits shoulder motion: abduction and adduction, flexion and extension, internal and external rotation
  • Generally custom molded for small children
  • Prefabricated options for adolescent or larger children
  • Immobilizes arm in shoulder adduction and internal rotation, with elbow flexed
  • Pediatric sizes available with smaller envelopes to free fingers
Sling and Swathe (Shoulder Immobilizer Sling)
  • Sling combined with rotation-control thoracic strap
  • Further immobilizes the shoulder and prevents abduction and flexion
Figure 22-14 Elbow-wrist-hand orthosis.

Figure-of-Eight (Clavicle Strap)
  • Prevents scapular protraction and encourages scapular retraction
  • Postural correction, clavicle fracture management
  • Can be added to spinal orthosis for kyphosis correction
Spinal Orthoses
Cervical Orthosis (CO)
  • Soft collar
    • □ Support for cervical muscle spasms or minor ligamentous injuries
    • □ Serves simply as kinesthetic reminder, provides soft tissue warmth
  • Hard collar
    • □ Limits sagittal motion better than the soft collar
    • □ Support for muscle spasms and atlantoaxial rotary subluxation
    • □ Many types: Philadelphia, Aspen (Fig. 22-15), Miami J
Cervicothoracic Orthosis (CTO)
  • Increases stability of cervical orthosis alone by extending inferiorly over thoracic region
  • Addresses C1 fractures without subluxation, stable hangman fracture, and flexion injuries of C3-C5
  • Minerva
    • □ Plastic with removable liner
    • □ Good flexion control
  • SOMI: sternal occipital mandibular immobilizer
    • □ Can be easily applied in a supine position
    • □ Good flexion control, limited extension control
  • Halo (Fig. 22-16)
    • □ Addresses unstable cervical injuries
    • □ Most rigid control through skeletal fixation
    • □ Excellent flexion, extension, and rotation control
Lumbosacral Orthosis (LSO)
  • Addresses acute or chronic low back pain, acute low back and leg pain, sacroiliac disorders
  • Support from L1 to L5
  • Provides varying degrees of abdominal support, motion control, and pain relief
  • Nonoperative and operative types
    • □ Corset or elastic wraparound styles sized (OTS)
    • □ Rigid plastic LSO (custom molded)
Figure 22-15 Aspen cervical collar.
Figure 22-16 Halo.
Thoracolumbosacral Orthosis (TLSO)
Addresses fractures (e.g., anterior compression, burst),
congenital malformation, neurologic disease with muscle paralysis,
spondylolisthesis, disc herniation, stenosis
  • Hyperextension TLSO (Jewett, CASH): addresses anterior compression fracture and prevents flexion
  • Knight-Taylor TLSO
    • □ Fabricated from measurements only
    • □ Applicable for obese patients
    • □ Easily accommodates weight fluctuations
    • □ Provides good ventilation
  • Custom-molded TLSO
    • □ Provides intimate fit and maximum control of flexion, extension, lateral flexion, and rotation
    • □ Can be molded in desired position (Fig. 22-17)
  • TLSO with thigh extension: used to control motion at L5-S1 level
  • P.249
  • Scoliosis—TLSO
    • □ Used to manage idiopathic (not neuromuscular) scoliotic curves from 25 to 40 degrees
    • □ Uses specific trim lines to a module with interior pads to apply counteractive forces
    • □ Boston brace: worn up to 23 hours a day (Fig. 22-18)
    • □ Charleston bending brace (overcorrection): molded in bent position to reverse scoliotic curve; nighttime use only
    • □ Wilmington, Lyon, Milwaukee: used to address higher thoracic curves
Figure 22-17 Molded thoracolumbosacral orthosis.
Figure 22-18 Scoliosis—thoracolumbosacral orthosis.
Cervicothoracolumbosacral Orthosis (CTLSO)
  • Cervical extension added to TLSO to address multiple spinal injuries
  • Halo, Minerva, or SOMI extension may be added to TLSO depending on stability needed
  • Milwaukee CTLSO
    • □ Addresses kyphosis or high scoliotic curves
    • □ Very low compliance because of metal extensions in cervical region
JG, Carter PR, Cummings DB, et al. Limb deficiencies. In: Herring JA,
ed. Tachdjian’s pediatric orthopaedics, 3rd ed. Philadelphia: WB
Saunders, 2002:1745-1810.
JH, Michael JW, eds. Atlas of limb prosthetics: surgical, prosthetic,
and rehabilitation principles, 2nd ed. St. Louis: Mosby-Year Book, 1992.
Goldberg B, Hsu JD, eds. Atlas of orthoses and assistive devices, 3rd ed. St. Louis: Mosby-Year Book, 1997.
Herring JA, Birch JG, eds. The child with a limb deficiency. Rosemont, IL: American Academy of Orthopaedic Surgeons, 1998.
RT, Giavedoni B, Coulter-O’Berry C. The limb-deficient child. In:
Morrissy RT, Weinstein SL, eds. Pediatric orthopaedics, 5th ed.
Philadelphia: Lippincott Williams & Wilkins, 2001: 1217-1272.

This website uses cookies to improve your experience. We'll assume you're ok with this, but you can opt-out if you wish. Accept Read More