EQUIPMENT

By admin On Dec 15, 2022

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

EQUIPMENT

Clifford L. Craig

Nicole Parent

Mark D. Clary

Robert N. Hensinger

WHEELCHAIRS

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

Assistive devices enlarge the base of support in stance
and swing phase of gait, enhance balance, and decrease the
weightbearing load.

Types

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)

PROSTHETICS

Prescribing a prosthesis for a child is particularly
challenging given the dynamics of growth, activity level, and variable
motor coordination.

Principles

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
- □ Exoskeletal: wood or polyurethane covered by plastic laminate; more durable

TABLE 22-1 WHEELCHAIR VARIABLES

Variable		Choices	Description
Weight		Ultralight	22 lb
		Lightweight	30 lb
		Standard	40 lb
Frame		Folding	More portable
		Rigid	Lighter
Components
	Wheels	Mag	Solid plastic
		Spoke
	Tires	Pneumatic	Air-filled
		Solid
	Hand rims	One-arm drive	For hemiplegics—where the user grips to propel the wheels
		Quad projections	Rubber extensions for improved leverage
	Wheel locks	Standard
		Brake extensions	Positioned at front of seat for ease of access
	Back frame	Reclining	Changes orientation by seat to back and knee angles
		Tilt-in-space	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	Standard
		Tubular swing-away
	Foot rests	Rigid	Built into frame
		Swing-away	Can be moved to facilitate transfers
		Elevating
	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
- □ 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

TABLE 22-2 ACRONYMS USED: ORTHOTIC AND PROSTHETIC PRESCRIPTIONS

Acronym		Stands for	Notes
Orthoses
Lower limb
	FO	Foot orthosis
	AFO	Ankle-foot orthosis	Solid, articulated, PLS, conventional (metal); custom molded or prefabricated
	KAFO	Knee-ankle-foot orthosis	Single or double upright
	HKAFO	Hip-knee-ankle-foot orthosis	May be bilateral or unilateral
	RGO	Reciprocating gait orthosis	Type of HKAFO; allows hip flexion in swing, stability in stance
	SMO	Supramalleolar orthosis	Controls subtalar motion, allows limited plantarflexion and dorsiflexion
	UCBL	University of California, Berkeley, Laboratory orthosis	Orthosis was designed there; addresses flexible hindfoot deformity
	SAAJ	Single-action adjustable joint	One channel only
	DAAJ	Double-action adjustable joint	Two channels for control of dorsiflexion and plantarflexion (assist and stops)
Upper limb
	HO	Hand orthosis	Does not extend or control wrist
	WHO	Wrist-hand orthosis	May or may not have thumb spica
	EO	Elbow orthosis	May be protective or stretching
	EWHO	Elbow-wrist-hand orthosis	Extends over wrist in addition to elbow
	SEWHO	Shoulder-elbow-wrist-hand orthosis
Spine
	CO	Cervical orthosis	Cervical collar
	CTO	Cervicothoracic orthosis	Minerva or Somi
	SOMI	Sternal occipital mandibular immobilizer	Type of CTO
	LSO	Lumbosacral orthosis	Addresses injuries L1-L5
	TLSO	Thoracolumbosacral orthosis	Addresses injuries T4-L5
	CTLSO	Cervicothoracolumbosacral orthosis	Cervical extension for injuries above T4 in addition to other thoracic or lumbar injury
Prostheses
Sockets
	PTB	Patellar tendon bearing
	SC	Supracondylar
	SCSP	Supracondylar suprapatellar
Other
	SACH	Solid ankle cushion heel	Used for prosthetic feet
	OTS	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.

ORTHOTICS

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

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

TABLE 22-3 JOINT MOTION CONTROL OPTIONS

Type	Description
Free	No restriction in plane of motion, with medial and lateral stability
Assisted	Spring added to increase range and velocity
Resisted	Spring added to decrease range and velocity
Stop	Blocks all motion or limits to a specific range
Lock	Mechanism to block motion when engaged

Lower Extremity Orthoses

Shoes

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

BOX 22-1 ESSENTIAL ELEMENTS OF AN ORTHOTIC PRESCRIPTION

Date
Institution or office or origination
Patient’s name, age, gender, address, telephone number
Diagnosis: status post is not sufficient; condition for which the surgery was done is also required
Description of the orthosis and orthotic goal
Acronym for orthosis and description of the motion control of each joint
If shoes to be attached to or fit over the orthosis, include modifications
Justification for orthosis (letter of medical necessity)
Inclusion of office note may be sufficient

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

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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

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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
- 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

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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

Sling

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.

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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

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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