Pediatric Orthoses

1. Pediatric Orthoses

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

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

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.

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, ligamentouslaxity, 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

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.

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 pesvalgus. Orthoses for angular disorders benefit from high posting and out-flared or wide posts to stabilize the post plate in the frontal plane.

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.

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

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 • Calcanealapophysitis (Sever’s 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.

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

12. D-DAFO

13. 1 Low Profile D-DAFO • Provides dynamic alignment and support for the foot and ankle • Allows plantar flexion and dorsiflexion

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.

15. 3 Solid Ankle AFO • Application: Varum and valgus deformities • Description: Custom-fabricated thermoplastic, metal or composite device designed and trimmed for a patient’s unique needs • Function: Provide proper alignment, block plantar flexion and dorsiflexion

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.

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

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.

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.

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

21. Indications • Hip fractures/replacement • Femur fractures • ORIF’s, 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.

22. 9 Counter Rotation system • An improvement on the Denis Browne splint for post club foot release splinting • Description: Plastic multihingedorthosis 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.

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

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 gastrocsoleus (calf) muscles. • A floor reaction AFO places the extension force closer to the knee than other AFO’s 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.

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

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.

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

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

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.

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.

31. 20 PonsetiOrthosis • 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

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.

33. CLINICAL INDICATIONS • Cerebral Palsy or other neuromuscular diseases • Idiopathic toe walking • Severs disease • Tightness at the foot and ankle • Following achilles tendon lengthening

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 patient’s 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.

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.

36. Rooster Boots

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.

39. 3Roosterbootwith 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.

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.

41. C. Cranial • Cranial remolding orthoses is used to treat deformational plagiocephaly, brachycephaly, scaphocephaly and other head shape deformities in infants 3—18 months of age. • These orthoses can be used to effectively manage a broad spectrum of head shape deformities and clinical indications. 

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.

43. D. Spinal • Complementing the standard range, spinal orthoseshave 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.

44. New Options PL1 Elastic Double-side pull lumbar support • Features 6" wide elastic belt, two 2" wide adjustable side pulls that overlap in front to increase support and 1/16" nylon 2-sides neoprene pocket for insert.

45. E. SHOULDER and ARM Shoulder Abduction rotation orthosis (SARO) • Increased adjustability at the shoulder and elbow joints • Humeral cuff with raised posterior wall for additional control • Lightweight, universal, design can be used for the left or right shoulder INDICATIONS: • Paralysis or damage to the Brachial Plexus (Erb palsy) • Prevention of upper extremity joint contactures • Brachial Plexus exploration and nerve repair • Soft tissue surgery including tendon transfers

46. F. WRIST & HAND 1 DEROYALE • Unique wrist, hand and finger orthosisapplys low stretch therapy to contracted fingers, hand and wrist. Features dynamic inflatable air bladders. Fleece type liner helps reduce pressure points and provide comfortable fit.

47. Fillauer Pediatric Action Wrist Support • 1/8" nylon two sides neoprene. Circumferential adjustable wrist strap. Hook and loop closures. Removable splint for washing.

48. Comfy Splints Pediatric Hand Wrist Orthosis • Provides support and positioning for weak or deformed hands at the wrist, hand and fingers. It serves as an excellent resting splint to prevent trauma to joints and positions to increase ROM. The wings on the side adjust to prevent ulnar or radial deviation and to allow for custom fit and comfort. 

49. Comfyprene Pediatric Separate Finger Hand Orthosis • The Comfyprene Pediatric Separate Finger Hand Orthosis unique splint allows for individualized finger adjustments. Excellent for many deformities, including; dupytrens, swan neck or boutonneire contractures, as well as sprains and fractures. Comes with Finger Separator and available in Left or Right.

50. Comfy Splints Pediatric Hand Thumb Orthosis • Is uniquely designed to support the thumb without stressing the web space between the index finger and the thumb, known as the thenar eminence. The thumb tab functionally positions the thumb without stretching the thenar eminence like the traditional “C” bar opposition hand splints, making this splint excellent for use on patients with tightly adducted thumbs. The splint is adjustable and re-adjustable without the use of tools, making it easy to use and customize.