Slide 2 Most orthoses made for children are motion- controlling
or motion-altering Accommodative devices are less frequently
required in this age group. The relatively light weight of a child
means materials that are more forgiving with increased flex in a
heavier individual such as an adult will resist collapse more
readily in a child Slide 3 This allows you to choose from a wide
range of material properties, shell thicknesses and filler options
while still achieving the desired goal of motion control The ideal
orthosis for a child will limit excessive or undesired motions
while still allowing normal motions that are so important for ideal
development Slide 4 Key Posting Considerations Dynamic
compensations for Varus deformities of the rearfoot and leg require
POSTING The amount of control a post provides is determined by
numerous factors: the number of degrees the post is angled the
stiffness or resistance to compression of the posting material
anterior-posterior length of the post and the width of the post A
longer, wider post made of a stiffer material will offer the most
control to the rearfoot and leg There is a reduced need for
forefoot posting in children under the age of 6. Slide 5 Be Aware
Of Predisposing Risk Factors In The Pediatric Pronated Foot A child
may exhibit a weak foot structure leading to pronation, but may
also have additional predisposing risk factors that may affect the
foot in its overall development and function. These risk factors
include, but are not limited to, ligamentous laxity, obesity,
rotational and angular disorders and ankle equinus Shells made of
more rigid materials and/or of increased thickness are the best
choices for treating children who have generalized ligamentous
laxity Slide 6 Other modifications such as a deep heel seat,
increased calcaneal pitch to lock the oblique midtarsal joint axis
and medial and lateral flanges to reduce transverse plane
compensations of the midfoot will aid in control of the foot with
notable laxity Thicker shells and more rigid materials are also
necessary in managing the pronated foot in the obese child
Longitudinal arch fillers will help reduce the increased
compression of the arch area of the shell in overweight patients.
Soft tissue supplementation at the foot/orthosis interface may help
reduce the hard feel of such devices and increase shock absorption
necessary for sports. Slide 7 How To Handle Rotational And Angular
Disorders Rotational and angular disorders that produce both in-
toeing and out-toeing, bowing and knock-knees may contribute to a
compensatory pes valgus. Orthoses for angular disorders benefit
from high posting and out- flared or wide posts to stabilize the
post plate in the frontal plane. Slide 8 Treatment Tips For Ankle
Equinus Fully compensated equinus foot, often characterized by
pronation of the subtalar joint with consequent unlocking of the
oblique midtarsal joint axis to allow for dorsiflexion and
abduction to occur at the midfoot, is a major cause of pediatric
pronation Childhood ankle equinus may be developmental or
pathologic: Developmental equinus typically accompanies a rapid
bone growth spurt, resulting in relative shortening of the muscles
Pathologic equinus may be congenital or result from other etiologic
causes Both exert harmful forces on the foot, either initiating
abnormal pronation or aggravating pronation already present in the
child. Slide 9 In addition to stretching the tight musculature,
orthotic control of the abnormal midfoot is usually necessary
Adding heel raises to an orthotic device to plantarflex the foot
and increasing the amount of available dorsiflexion of the ankle
for midstance are effective at helping to reduce compensation in
this foot type In addition, the presence of equinus may limit the
degree of control that can be tolerated by Slide 10 Other Helpful
Treatment Insights Patients with a talocalcaneal coalition have
reduced subtalar joint motion and frequent peroneal spasm.
Employing a rigid orthosis from a pronated cast with a deep heel
seat and a 0- degree rearfoot post is often successful at reducing
painful motion When you treat children with a calcanonavicular
coalition, keep in mind that reduced subtalar joint motion and
peroneal spasm are less common Calcaneal apophysitis (Severs
disease) is an inflammation (sometimes considered an
osteochondrosis) of the secondary growth center of the calcaneus.
It is frequently accompanied by a tight heel cord and may be
aggravated by high loads through the heel. Slide 11 PEDIATRIC
OTHORSES A. LOWER EXTREMITIES D-DAFO Dynamic Ankle-Foot Orthosis
(also called Tone Reducing AFO and Total Contact AFO) A dynamic,
total contact orthosis which works exceptionally well for children
with spasticity. Maintains the correct alignment of the bones in
the foot and ankle. Application: Cerebral palsy, hemiplegia,
spastic diplegia Description: Thin, flexible, molded thermoplastic
orthosis covering the entire foot; custom-contoured footplate;
designed to distribute weight-bearing forces over large area
Function: Reduce ankle hypertonicity, increase ankle stability and
provide proper alignment Slide 12 D-DAFO Slide 13 1 Low Profile
D-DAFO Provides dynamic alignment and support for the foot and
ankle Allows plantar flexion and dorsiflexion Slide 14 2 Full
Length D-DAFO The dynamic design and material work on volume and
will remain very comfortable even as children begin to outgrow
them. This feature allows more time in the orthoses and a decrease
in the likelihood that the patient will be unable to wear them
before a new, larger D- DAFO is needed Blocks plantar flexion and
allows dorsiflexion. Slide 15 3 Solid Ankle AFO Application: Varum
and valgus deformities Description: Custom-fabricated
thermoplastic, metal or composite device designed and trimmed for a
patients unique needs Function: Provide proper alignment, block
plantar flexion and dorsiflexion Slide 16 4 Solid Ankle AFO w/
pre-tibial shell (anti-crouch) This Solid Ankle AFO with anterior
panel is designed to prevent dorsiflexion and plantar flexion. The
'ground reaction' will also help to push the knee into extension
during weight bearing. Slide 17 5 Articulating AFO Allow flexion at
the ankle and has an adjustable/removable plantar flexion stop It
is also possible to add dorsiflexion assist or check straps Slide
18 6 UCBL Custom made insert for controlling a hyper-mobile
pes-planus or cavus. It supports the arches of the foot and
maintains the relative position of the hindfoot, midfoot, and
forefoot. Slide 19 7 Reciprocating Gait Orthosis Provides
parlalitic patients with the support and ability to stand and take
steps with assistance The entire system can wiegh as little as 3.5
lbs. for smaller patients RGO is the most frequently used brace for
the ambulatory needs of a paralyzed child or adult Description:
HKAFO incorporating cable system or similar method of mechanically
translating hip extension on one side into hip flexion on the
contralateral side. Application: Lower-body neurologic impairment
indicated in L1-L3 lesions in children with functioning iliopsoas
and hip adductors. Function: Provides standing and ambulation
ability thereby raising physical and psychological horizons. Slide
20 8 HKAFO (hip-knee-ankle Foot Orthosis) Used on patients
requiring more stability of the hip and lower torso, due to
paralysis and weakness, in addition to the lower extremity
involvement. The brace will provide pelvic stability in several
planes, from rotation, to side-to-side, and front-to-back motions
Purpose of the Device Provides adjustable control of the hip, knee
and ankle. Manual locks maybe added to hip and knee joints Ankle
motion maybe fixed or adjustable Slide 21 Indications Hip
fractures/replacement Femur fractures ORIFs, Hip, Femur, Tibia
Common Additions Anterior tibia shell Locking knee Range of motion
knee joint Range of motion Hip joint Padded liners PRAFO foot plate
Locking Hip Special Considerations Patients who will be
bed-to-chair for an extended time should be fit with a PRAFO
distally to prevent heel breakdown. Slide 22 9 Counter Rotation
system An improvement on the Denis Browne splint for post club foot
release splinting Description: Plastic multihinged orthosis with
bilateral footplates; three hinged joints and eight circular
rotation joints. Application: internal tibial torsion, maintenance
of post- operative clubfoot or metatarsus adductus correction.
Function: hold feet in corrected external or internal rotated
position while allowing independent leg movement and free hip and
knee motion. Slide 23 10 Developmental dysplasia of the hip (DDH)
orthosis Description: Pelvic band connected to thigh cuffs by
aluminum joint with 20 degree extension stop and 90 degree flexion
stop or free motion Application: Hip dysplasia in children beyond
pre- walking stage Function: Provide positive abduction positioning
Slide 24 11 Floor reactions orthosis used with patients affected by
neurological conditions such as spina bifida, cerebral palsy, brain
injury, spinal cord injury, and post-polio paralysis. In these
cases, the floor reaction AFO functions to maintain the affected
joints in proper alignment, to accentuate knee extension at
midstance, and compensate for weak or absent gastroc soleus (calf)
muscles. A floor reaction AFO places the extension force closer to
the knee than other AFOs and uses a rigid anterior shell with
padding Description: Rigid thermoplastic or laminate AFO with
neutral ankle position and a broad anterior panel just below the
knee Application: Cerebral palsy crouch gait - Knee instability
Function: Apply knee extension moment during stance phase to
prevent knee buckling and excessive flexion associated with crouch
gait. Slide 25 12 Orthopedic shoes Shoes that are specially
designed shoes that provide support and pain relief for people
suffering with some type of pain in the legs, ankles, or feet.
Description: Specially shaped extra-depth design Application:
Correction and accommodation of foot deformities Function:
Accommodate for internal modifications Slide 26 13 Parapodium
Application: Paraplegic patient, spastic cerebral palsy
Description: lightweight, high-strength aluminum and footplate,
used to lock and unlock the hip and knee joints. Function: For
stability, the footplate, sidebars, and back panel form a
continuous rigid loop, cross-braced by a bar at the level of the
knee. The shape of the bar virtually eliminates side-to-side
movement, thus improving the anterior-posterior and medial-lateral
stability of the unit. Slide 27 14 Scoliosis Jacket Application:
Idiopathic scoliosis Description: Custom thermoplastic TLSO
Function: Limit curve progression and need for surgical correction
15 Scottish Rite Orthosis Application: Legg-CalvePerthes disease
Description: Lightweight orthosis consisting of metal pelvic band,
plastic thigh cuffs, aluminum hip joints with thrust- bearing hip
joints or a telescoping spreader bar (older design) Maintain hips
in abduction containing femoral head in the acetabulum Slide 28 16
SWASH (Standing, Walking and Sitting Hip Orthosis) Application:
Cerebral palsy; any child whose adduction and/or internal rotation
at hip joint interferes with function or induces lateral migration
of the femoral head Description: Plastic padded waist band and two
joint assemblies connected by shaped leg bars to adjustable plastic
thigh bands Function: Stabilize hip and oppose excessive adduction
and internal rotation; reduce scissor gait while walking and
improve balance while standing 17 Tibial Fracture Orthosis
Application: In lieu of plaster cast to provide greater freedom of
activity during healing, reduced muscle atrophy and shorter
disability time Description: Total contact, usually thermoplastic,
brace with plastic or metal ankle joints and heel insert. Most
often custom- molded for pediatric applications Function: Allow
mobilization of the leg during fracture healing; minimize rotation
and sheer forces support tibia and fibula Slide 29 18 Wheaton Brace
Application: Metatarsus adductus; clubfoot; tibial torsion. Used in
place of serial casting or corrective shoes Description: Molded
thermoplastic and Velcro knee ankle- foot orthosis Function:
Applies direct corrective rotational force on the tibia without any
torque on the femur or hip. Slide 30 19 Dennis Brown Bar The Dennis
Brown Bar attaches to corrective shoes to maintain proper hip and
foot position. The adjustable rotation allows for desired
external/internal rotation. Slide 31 20 Ponseti Orthosis Abduction
device similar to Dennis brown bar with total contact AFO section
that delivers excellent correction of clubfoot (deformity with a
downward and inward pointed foot) without the risk and
complications of foot surgery Slide 32 21 Pediatric UFO The
pediatric UFO from Orthomerica is a comfortable, prefabricated
orthosis for stretching and maintaining dorsiflexion range of
motion. This unique lower-limb orthosis positions the foot and
ankle in optimal alignment for placing stretch on the soleus while
the patient is sleeping. When used in conjunction with a knee
immobilizer, this orthosis can also stretch the two-joint
gastrocnemius group. Slide 33 CLINICAL INDICATIONS Cerebral Palsy
or other neuromuscular diseases Idiopathic toe walking Severs
disease Tightness at the foot and ankle Following achilles tendon
lengthening Slide 34 B. NIGHT TIME Night Stretching Orthoses
Designed to increase and maintain ROM and maintain joint alignment
during the night. Dynamic orthoses provide an adjustable stretch
that will follow the patients ROM as it increases. It also allows
for flexion/ extension within the orthosis when the patient is
awake and provides a long term, low-load stretch while they are
relaxed. Slide 35 1. Roosterboot The Rooster boots are available in
varying colors which each patient can choose at their casting
appointment. Rubber sole on the Rooster boots so that children can
get up to use the restroom during the night without slipping and
falling or having to remove the orthosis It is designed to provide
an adjustable, dynamic stretch to the heel cords. The
custom-overlapping padding provides total contact for pressure
reduction and maintaining correct alignment. Slide 36 Rooster Boots
Slide 37 2. KAFO with the D-DAFO This KAFO has a dynamic stretching
joint at the knee and incorporates the D-DAFO. This design is made
for children with severe spasticity and/or malalignment throughout
the foot and ankle. The D-DAFO provides a very intimate, total
contact hold for correction and pressure distribution. Holding the
ankle at 90 degrees and maintaining correct alignment throughout
the foot is crucial for achieving an effective stretch on the
gastrocnemius. Slide 38 Slide 39 3 Roosterboot with KO attachment
This KAFO is in two parts. The knee orthosis snaps onto the
Roosterboot. Both the knee and ankle have dynamic adjustable joints
for comfort and stretch. Making this in two parts allows parents
the option of using only the Rooster boots at certain times. The KO
section also be fabricated at a later date once need is determined.
Slide 40 4 Dynamic KAFO a. This parrticular KAFO has dynamic
stretching joints at both the knee and ankle. Each joint can be
adjusted for patient cofort and maximum stretch. b. This Dynamic
KAFO has a dynamic joint at the knee only. The ankle is held at 90
degrees and in correct alignment. Slide 41 C. Cranial Cranial
remolding orthoses is used to treat deformational plagiocephaly,
brachycephaly, scaphocephaly and other head shape deformities in
infants 318 months of age. These orthoses can be used to
effectively manage a broad spectrum of head shape deformities and
clinical indications. Slide 42 Orthomerica Orthomerica's A-Flex
Protective Headgear is an adjustable alternative to other hard
protective devices. It is fabricated from a flexible plastic that
readily conforms to varying head shapes, making it easy to fit upon
demand. The protection is ideal for low impact forces that are
distributed (like a shock absorber) across the entire surface
without cracking or penetrating. The headgear is equipped with
easy-to-adjust straps minimizing the need for chin straps. Optional
chin straps are recommended for active and noncompliant patients
The posterior strap "locks" the device below the mastoids and
accommodates size variations while the lateral straps are used for
easy donning and doffing. Lateral straps and side-slits are also
optional. The A-Flex features ventilation holes to reduce trapped
heat. It can be easily trimmed with a pair of shop snips without
the need for complex equipment and tools. Slide 43 D. Spinal
Complementing the standard range, spinal orthoses have been
designed to accommodate the unique clinical needs and anatomy of
children, to provide the same high standards of protection and
support. Specially designed to fit the head shape of young
children, They ensure young patients enjoy the same quality of
care. Slide 44
