1.

Metal-leather and metal plastic KAFO

a. Double-upright metal KAFO has similar components as the AFO with the
addition of two metal uprights connected to a mechanical knee joint. The
uprights extend up the thigh and are emcompassed by two thigh bands.
Knee caps may be placed in front of the knee to prevent knee flexion
within the KAFO. For genu varum and valgum, the knee cap may include a
lateral or medial strap, respectively.
The mechanical knee joint may either be polycentric or single axis.
polycentric knee joints follow the natural motion of the knee joint more
accurately and are indicated if significant knee motion is required
during walking. Because most patients needing KAFOs requires knee
stabilization, a fixed or single axis knee joint is used more commonly.
The following are common types of single axis knee joints.
1. Free motion knee joint has unlimited flexion and extension nut
usually has a stop to prevent hyperextension. It is indication for
patients with a tendency toward genu recurvatum and mediolateral
instability but with enough strength to control the knee during
weight bearing and ambulation
2. Offset knee joint is a hinge placed posterior to the knee joint so that
patients weight line falls anterior to the offset joint, thus stabilizing
the knee during early stance phase of gait on level surface. It allows
to knee to flex freely during swing phase and also allows sitting
without the need to manipulate the lock.
3. Locked knee joints are used to prevent knee buckling. To be able so
lock the knee joint, the patient must be able to fully extend the
knee, either actively and passively. They are contraindicated in
patients with knee contracture.
a) Drop-ring locks consist of a ring that can be dropped over the
knee joint while the uprights are fully extended, thus preventing
the uprights from bending. For KAFO with bilateral uprights, both
medial or lateral joints must locked for greater stability. A spring
loaded retention button allows the patient or therapist to unlock
one upright then attend to the other one without having the first
lock drop. As the patient sits, the retention button can be used
to unlock one knee so the patient can grasp chair with one hand
for stability and use the other free hand to unlock the other
upright. For KAFO unilateral uprights, a spring-loaded retention
pull rod may be added to the drop ring so the patient need not
bend in unlock or lock joint. Droprings are the commonly used
knee to control knee flexion.
b) Pawl lock with bail release consist a spring loaded projection that
fits in to matching recess when the knee is fully extended thus
providing simultaneous locking of both uprights. It also have
semicircular level attached posteriorly, which easily unlocks both

joints with an upward pull on the bail. The bail is bulky and
accidentally can be released if it hits a rigid object.
4. Adjustable knee joint has a proximal component consisting of a
drop ring lock and a distal component consisting of an adjustable
knee lock, which can either be a fan lock, a serrated disk, a dial
lock, or a ratchet lock. The drop ring, which maintains the desired
knee position in standing and walking, can be unlocked to permit
full knee flexion when sitting. The adjustable knee joint permits
locking in different degrees of flexion as the patients knee joint are
used to provide stability in patient with knee flexion contractures in
whom improvement is anticipated with gradual stretching.
b. Single lateral-upright metal KAFO has a lateral upright only, with thigh and
pretibial cuffs made of molded plastic. All the other components are the
same as in the double upright metal KAFO
c. Scott-Craig mteal KAFO is custom-made for standing and ambulation in
adults with paraplegia. It consists of double uprights, a pawl lock with bail
release, a posterior thigh band, a hinged pretibial band, a bichannel
adjustable ankle lock (BiCAAL) joint and a shoe with cushion heel and
embedded with a longitudinal and transverse foot plate. The longitudinal
plate extends from the heel to the metatarsal heads to provide a rigid
platforms., while the transverse plate located at the metatarsal head
region provides mediolateral stability. BiCAAL joint is the set in about 10
degrees dorsiflexion so the orthosis and the patients limb lean forward
slightly. To attain balance, the patient compensates by hyperextending the
hips to bring the center of gravity behind the hip joints and in front of the
locked knee and ankle joint thus preventing untoward hip or trunk flexion.
Some patients may able to use two or four point gait by shifting the trunk
enough to allow the leg to swing forward in a pendular manner. The ScottCraig KAFO provides orthotic stabilization of the knee ankle and foot, and
passive or ligamentous stabilization of the hip without recourse to orthotic
components at or above the hip.
2. Plastic and plastic-metal KAFOs us thermoplastic materials because they are
lighter, more cosmetically acceptable, and can be heated for the better
contour. Plastic and plastic-metal KAFOs are indicated for closer fit and more
precise control of pressure and for maximum control of the foot.
a. Supracondylar plastic KAFO is custom-made plastic orthosis extending
from the ankle and foot up to the knee and lower thigh to resist
recurvatum forces of the knee without hindering flexion and to provide
mediolateral stability. In patients with knee extensor weakness, the ankle
and foot components are used to hold the ankle in slight plantarflexion,
enough to produce a knee extension moment and eliminate the need for a
mechanical knee lock in stance. Its advantages is that when patient sits
the suprapatellar portion protrudes. Also it cant be used bilaterally

because positioning the ankles in plantarflexion interferes with the

patients anteroposterior stability.
b. Supracondylar plastic-metal KAFO has the same functionand design as the
supracondylar plastic KAFO except that it nhas conventional metalknee
joints and uprights to allow orthosis to flex while the patient is seated and
thus decreasing protrusion above the knee during sitting
c. Plastic shells and metal uprights KAFO are essentially a posterior leaf
spring AFO with double metal uprights extending up to a plastic thigh shell
with an intervening knee joint. The proximal contour of the thigh shells are
usually quadrilateral in shape to help control rotation and may incorporate
an ischial seat for weight bearing.
E. Knee orthoses (KO) provide support or control of the knee but not the foot and
ankle. Their designs are determined by their function. As with KAFOs, their
orthotic knee joint is usually centered over the medial femoral condyle.
1. knee othoses for patellofemoral disorders control tracking of the patella as the
knee flexes and extends.
a. Interpatellar (Cho-Pat) strap KO is a foam-padded strap that encircles the
knee immediately below the patella. They are worn during periods of activity.\
b. Palumbo KA uses an elastic sleeve with patellar cutout, two
circumferentially wrapped rubber straps that apply tension to a crescentshaped patellar pad, and an elastic counter force strap, which maintains
positions of the pad and prevent s axial rotation of the orthosis.
2. knee orthoses for knee control in the sagittal plane controls genu recurvatum
with minimal mediolateral stabilization. They allow almost complete knee flexion.
a. Swedish knee cage is a fabricated brace, which restricts hyperextension
with two anterior straps and one posterios strap held in position by the metal
frame medially and laterally. It tends to protrude when the patient sits.
b. three-way knee stabilizer it has pivotable attachments of the straps, which
do not protrude as much in sitting. It has lateral and medial uprights which
provide limited mediolateral stability.
3. Knee orthoses for knee control in the frontal plane consist of thigh and calf
cuffs joined by side bars with mechanical knee joint. In addition protecting the
knee against mediolateral forces. They also provide flexion-extension control by
including a hyperextension stop in the mechanical knee joint or by adding a drop
lock. The knee joint is usually polycentric to closely approximate anatomic knee
motion and contribute better stabilization of the orthosis on the patients limb.
a. traditional metal leather KO has leather thigh and calf cuffs and metal side
bars. A pressure pad may be used to aplly medial or lateral forces to the knee.

b. Miami KO has side bars and polycentric joints incorporated in to

polypropylene calf and thigh shells, which cove the anterior limb surfaces.
c. CARS-UBC KO consist of two plastic cuffs connected by a telescoping rod,
which permits knee flexion. For genu varum, the rod is placed on the medial knee
with a pad on the lateral knee while for genu valgum, the rod is placed on the
lateral knee with a pad on the medial knee. Thos three-point pressure system
resists varus / valgum forces when the knee is fully extended and is weight
bearing.
d. Supracondylar KO is similar to supracondylar KAFO except that it does
have an ankle or foot extension. It controls genu recurvatum and provides
mediolateral knee stabilization. The suprapatellar portion protrudes off the thigh
when the patient is seated.
4. KO for axial rotation control also provides angular control in the sagittal and
frontal planes. In addition to controlling axial rotation. They are used in the
prevention and management of sports injuries of the knee.
a. Lenox-Hill derotation orthosis uses close-fitting cuffs or elastic straps that
encircle the thigh and leg
b. Lerman multiligamentous knee control orthosis is similar to Lenox-Hill
derotation orthosis with the addition of supracondylar pads for additional control
of patellar tracking
F. Hip-knee-ankle-foot orthoses (HKAFO) consist of KAFO with the addition of a pelvic
band and hip joints. They are used to reduce gait deviatiobn caused by faulty
control of hip abduction, adduction and rotation. They are more difficult to don than
KAFOs, and if the hip joints are locked, they restrict gait to the swing to or swing
through pattern. Their orthotic knee joint is usually centered over the medial
femoral condyle, while their orthotic hip joint is positioned so that the patient can sit
upright at 90 degrees.
1. Pelvic band surrounds the lower trunk and attaches to the upper part of
the hip joint. They are likely to be uncomfortable when the patients sit.
a. Bilateral pelvic band is more commonly used than unilateral pelvic
band because most conditions requiring a HKAFO have bilateral involvement. It is
made of upholstered metal, which curves posteriorly and downward to contact the
most prominent portion of each buttock and continues slightly upward to overlie the
sacrum.
b. pelvic gridle made of molded thermoplastic materials provides
maximum degree of control in patient with bilateral involvement. It is similar to the
pelvic part of molded plastic thoracolumbosacral orthosis (TLSO) used for scoliosis.

c. Silesian belt attaches to proximal end of the lateral upright and

encircles the pelvis. It has no metal joint or rigid band. It offers mild resistance to
abduction and rotational forces at the hip.
d. Dacron webbing hip rotation strap may be used if the patient
requires only control hip rotation. To reduce internal rotation, a strap resembling a
prosthetic Silesian bandage is used. To reduce external rotation a strap tha passes
anteriorly at the groin and connects the lateral upright of the KAFOs is used
2. Hip joints and locks consist of metal hinges that connect the lateral
uprights of the KAFO to a pelvic band. By nature of its design, the hip joint also
prevent abduction and adduction, as well as hip rotation.
a. single axis hip joint with lock is the most commonly used hip joint. It
permits flexion and extension and may include an adjustable stop to limit
hyperextension. The flexion-extension capacity can be restricted by a pawl or dropring lock similar to those used at the knee joint. The drop-ring lock is useful if hip
flexion control is needed, especially in patients with a crouched gait.
b. Two-position lock hip joint can be locked at full hip extension an at 90
degrees of flexion. It is indicated in patients whose hip spasticity causes difficulty in
maintaining a seated position.
c. double axis hip joint ha a flexion-extension axis, which may be free or
locked and an abduction-adduction axis , which includes adjustable stops to place
limits on these motions as needed.
G. Trank-Hip-knee-ankle-foot orthoses (THKAFO) incorporates a spinal orthosis
attached to the HKAFO to control trunk motion, maintain or modify spinal alignment
and reduce loads on the spine by elevating intrabdominal pressure. The pelvic band
of the spinal orthosis serves as the pelvic band used on THKAFOs. It is indicated in
paraplegic patients but is seldom worn by patients after discharge from the
rehabilitation program because it is heavy, cumbersome and is very difficult to don.
As with HKAFO, their orthotic Lace joint is usually centered over the medial femoral
condyle; however their orthotic hip joint is positioned so that the patient can sit
upright at 90 degrees. Alternative designs of THKAFO available for paraplegic
patients are as follows:
1. Reciprocating gait orthosis (RGO) is a THKAFO consisting of a custom-molded
pelvic girdle with a thoracic extension and bilateral hip joints, which are connected
by one or two metal cables to prevent simultaneous bilateral hip flexion. Both knees
are stabilized with knee locks, posteriorly offset knee joints, or pretibial bands and
the feet are encased in solid ankle-foot orthoses. For walking, the hip joint can be
locked at 180 degrees or set to flex about 25 degrees. As the patient extends one
hip, the cable coupling induces hip flexion on the opposite supporting leg or vice
versa. This produce a reciprocal walking pattern not otherwise possible with

standard KAFOs or HKAFOs. Using two crutches, paraplegics can slowly ambulate
with a stable four or two point gait because one foot is always on the floor. When
standing, the cable coupling prevents simultaneous hip flexion. For sitting, the cable
can be released to enable the hips to flex. An RGO in combination with functional
stimulation, can be used for greater aerobic training in paraplegic and possibly
tetraplegic patients.
2. hip guidance orthosis or HGO is a THKAFO consisting of ball-bearing hip joints, a
body brace, and shoes that fit into loops on flat foot plates. The sturdy hip joints
guide hip motion in sagittal plane by using stops that limit hip flexion. Hip extension
may be free or may also be limited by a stop. Ambulation is through trunk motion
transmitter to the lower limbs through the brace. As the patient shifts weight from
side to side during ambulation, the hip joints resist hip abduction and adduction.
The gait maneuver is the similar to that used with the RGO.
3.Pneumatic THKAFO consists of a prefabricated long garment with inflatable tubes
both anteriorly and posteriorly. These tubes can inflated to provide rigidity and
deflated to allow flexion of the hips and knees. It is obsolete
4. Profabricated pediatric THKAFOs, which include standing frame, swivel chair, and
parapodium are beyond the scope of this book.

H. Hip Othoses consist of hip joints and pelvic bands with the lower bar of the hip
joint terminating on a thigh cuff. The thigh cuff may be extended to the medial
femoral condyle to provide additional resistance to adduction as wall as internal
rotation. It is most commonly used to resist spastic hip adductors in patients with
cerebral palsy. It may also be used after total hip arthroplasty to prevent hip
dislocation following total hip replacement by limiting adduction and flexion of the
hip joint. Their orthotic hip joint is positioned so that the patient can sit upright at
90 degrees.
1. Special-purpose lower-limb orthoses
1. weight-bearing orthoses reduce or eliminate weight bearing through the lower
limb. The skin and peripheral circulation on the weight-bearing area should be able
to tolerate pressure.
a. Patellar-tendon-bearing (PTB) orthosis has proximal designs similar to the PTB
socket used in below knee prostheses. It supports weight on patellar tendon and
tibial flares with the load being transmitted to the shoe via the metal uprights. It is
indicated for unloading the mid or distal of tibia, ankle, or foot. Because little or no
ankle motion is allowed, a cushion heel and a rocker bottom are added to provide
smoother gait pattern. A patter-bottom shoe may laso be used.

b.Ischial weight-bearing orthosis uses a quadrilateral brim to reliev weight from the
femur and knee. The ischial ring is simpler to fabricate but is uncomfortable and
less effective in relieving weight because forces are distributed over a smaller area.
A patten-bottom shoe may be used.
c. Patten-bottom orthosis uses uprights that terminate in a floor pad distal to the
shoe so the foot is freely suspended in midair. It is used conjunction with a PTB or
an ischial weight bearing orthoses so the weight is transmitted directly to the floor
pad. A shoe lift on the opposite side is needed to equalize leg length.
2. Fracture orthoses stabilize the fracture site and help promote callus formation by
allowing weight bearing and joint movement after an initial rest period to allow pain
and edema to subside. They also minimize joint stiffness and reduce complications
such as nonunions. Circumferential compression of the soft tissue can be used to
prevent undue bony motion at the fracture site.
a. tibial fracture orthosis consists of anterior and posterior thermoplastic plastic
shells fitted over the leg with Velero straps to ensure compression. Ankle motion is
controlled by the distal trimlines, or an ankle joint may be included and may have a
stop in either plantarflexion or dorsoflexion. It is used after the tibial and tibialfibular fractures have been immobilized for about 4 weeks. A design variation uses
plastic cable ankle joints connected to a plastic heel insrt to permit aknkle and foot
motion while preventing downward displacement of the orthosis. In a tibial plateau
fracture, stability may be increased by using a plastic thigh section connected via
polycentric knee joints to the distal segment.
b. femoral fracture orthosis consists of a thermoplastic thigh and calf component
connected via freely moving metal or plastic knee joints. The thigh component is
quadrilateral with an ischial seat proximally and is similar to the footplate by ankle
joints. It is used in fractures of the middle or distal third of the femur when there is
callus formation and relatively limited pain, usually after immobilization for more
than 4 to 6 weeks.
3. pediatric orthoses include those used for angular and rotational deformities of the
leg or foot., those that hold the hips in flexion and abduction in congenital hip
dislocations and those for maintaining the hip in abduction in Legg-Calve-Perthes
disease. They are, however, beyond the scope of this book.
B. Upper-limb orthoses are generally used to restore upper limb function by
assisting or supporting weak muscles, substituting for paralyzed muscle, protecting
painful or deformed parts, correcting existing deformities or malalignment,
permitting controlled directional movement, and allowing attachment of assistive
devices. The prescribed upper-limb orthosis should be properly fitted so the patient
can easily don and doff it and either rest the desired degment or perform the
prescribed movement comfortably when wearing the orthosis. Also, the orthosis
must be functionally as well as cosmetically acceptable to the patient. When

removed, the skin should be unblemished 10 minutes afterwards. Suggested upperlimb orthoses for common hand deformity because of upper-limb neurophaty. Most
wrist and hand orthoses can adequately be held in place using a strap, while othe
upper-limb orthoses neeed to be suspended from the torso for ambulatory patients.
Suspension systems commonly used include hoops, shoulder caps, and harnesses.
Traditionally, upper-limb orthoses are classified into static and dynamic.
Dynamic upper-limb orthoses improve upper limb functions through The Ude of
Joint, lever, pulleys, and External power sources. The above traditional
classification, however can be confusing because static orthoses are often use to
create movement; however dynamic splints usually have components that restrict
motion to create movement at another Joint, another way of classifying upper-limb
orthoses si by The anatomical Joint cover by orthoses for example, FO (finger
orthoses), WO (Wrist Orthoses), TO (Thumb Orthoses), WHFO (Wrist-hand-fingerorthoses) WHO (Wrist-hand orthoses), EWHO (Elbow wrist hand orthoses), EO (Elbow
orthoses), SEWHO (Shoulder-elbow-wrist-hand orthoses), SEO (Shoulder-elbow
orthoses), and SO (Shoulder orthoses). This anatomical classification, however,
doesnt indicate function. The folllowing classification, therefore, is used to combine
both function anatomy.
A. Wrist, Hand and Finger Orthoses
1. Assistive and substitutive orthoses are primarily used to enhance hand
function in patient with residual stregth. They are usually worn throughout
The day.
a) Positional orthoses
1) Opponents orthoses and their variations. are primarily used to
position The weak thumb in opposition to other fingers to improve
hand function by facilitating Three-jaw chuck pinch.
a) Basic opponens orthoses are TOs that consist of a dorsal and a
palmar bar that encircles The midpalm, with a thumb abduction
bar projecting from the palmar bar.
b) Opponens othoses with wrist Control attachments are WHFOs
that have a forearm bar as well as proximal and distal crossbars
for wrist control. In addition to the benefits provided by the
opponens orthoses, they provide the following, and prevents
wrist dorsi and volar flexion contractures and the cross bar helps
prevent ulnar or radial deviation deformities.
c) Opponens orthoses with lumbarical bar. Are FOs that prevent
MCP hyperextension but allow full MCP flexion. In addition to the
benefits provided by the opponens orthoses.

d) Opponens orthoses with finger extension assist assembly. Are

FOs that assist PIP and DIP extension. In addition, they alto
provide the previously listed benefits of the basic opponens
orthoses.
e) Opponens orthoses with thumb abduction-extension assist
assembly are TOs that assist thumb extension and abduction, in
addition to providing the benefits of the basi opponens orthoses.
2) Wrist control orthoses are used to promote slight extension of the
wrist or to prevent wrist flexion, thus assisting leak grasp.
a) Volar wrist-flexion Control orthoses. Are WHOs in which the
palmar section si extended. they are used to tighten finger
flexors and prevent wrist flexion contracture in patients with
radial neuropathy.
b) wire wrist-extension assist orthoses. are WHOs prefabricated
from spring steel wire and padded steel bands to assist wrist
extension by tensing the steel wire, thus aiding finger flexion
through tenodesis effect.
b. Prehension orthoses are used to stabilize the thumb while substituting
muscle stregth from other parts of the body or from an external Power source
to provide hand grasping, Holding and releasing functions. They are used in
patients with severe paralysis upper limb. The prehension pattern may be a
three-jaw chuck or a lateral grasp.
1) Hand prehension orthoses, such as finger driven hand prehension
orthoses. are FOs that provide prehension for the index and middle fingers.
Active MCP or IP flexion mus be present in at least One finger of the hand
2) wrist hand prehension orthoses can be anatomacally classified as
WHFOs
a) Finger-driven wrist-hand prehension orthoses substitute for the
weakened wrist ekstensor by means of forearm assembly, thus preventing
the fingers from dragging on the table when the patient writes or performs
similar tasks.
b) wrist-driven prehension orthoses are used in patients with c6
complete tetraplegi to provide prehension through tenodesis Action and
maintain flexibility of the hand, wrist and elbow.
c) passive prehension othoses have the same design as the fingerdriven wrist orthoses with the addition of a ratchet assembly, thus converting
it into passively operated othosis to provide grasp. The term passive si used

here to describe a mechanism that moves the stabilized fingers by gross

motion of the opposite hand or by pusing a lever against a table or similar
surface.
d) electrically driven prehension orthoses, pusing a cable,switch, motor
and battery, can be controlled by slight bodily movement.
c. Utensil Holder, consist of a handcuff with palmar pocker onto which the
utensil can be inserted. Most tetraplegics prefer them over the other
complex orthoses.
2. protective orthoses are used to protect the wrist, hand, and fingers from potential
deformity or damage by restricting active function while maintaining a desired
functional position. Most of them may be worn throughout the day and night to rest
the joint.
a. digital stabilizer
1) Finger stabilizer
a) distal interphalangeal stabilizers, are FOs covering the tip of the finger to
jus distal to the PIP volar crease to immobilize the DIP and allow unrestricted PIP
movement. when used in patients with distal extensor tendon repair, the DIP should
be positioned in slight DIP Hyperextension to tauke tendon for repair
b) Interphalangeal (IP) (PIP/DIP) stabilizers, are FOs usually used to restrict
motions at the PIP and DIP. In general, the IPs are maintained in full extension to kap
the collateral ligaments stretched and to prevent IP flexion contractures. They are
used to immobilize and promote healing and to provide prolonged finger stretch.
c) Ring Stabilizer
(1) swan Neck ring are FOs that prevent hyperextension of the PIP joint while they
perit flexion of alk joint. They are used in athritic patients with swan Neck deformity.
(2) Boutonniere ring, are FOs that immobilize the PIP in extension through a threepoint pressure system. They should be removed several times a day for ROM
exercise. They used in arthritic patients with boutonniere deformity.
d) Proximal interphalangeal hinged or articulated splints are FOs used to
provide mediolateral stability in patients with PIP strains, PIP volar plat injury, or
Post PIP surgery.
e) metacarpophalangeal ular-deviation restriction orthoses are FOs used to
limit ular deviation of the MCP with unrestricted MCP flexion/extension in arthritic
patients with ulnar deviation of the MCPs. Most patients find these orthoses too
cumbersomeand in severe cases, may choose to have MCP arthroplasty instead.

f) finger web-space stabilizer are FOs helm firmly in the finger web spaces to
increase or maintain the space between digits and prevent finger web-space
contractures.
2) Thumb stabilizer
a) Thumb corpometacarpal stabilizer are TOs that stabilize the First CMC and MCP
Joint in neutral position to protect the thumb against inadvertent motion. In patients
with Duck-bill deformity, thumb Post maintain the thumb in an opposed, abducted
position. Thumb Post may be extended distally to the thumb tip for use as an
opposition post or proximally over the midforearm to immobilize the wrist.
b) Thumb web-space stabilizer, are FOs that consist of a rigid C-shaped splint held
firmly in the thumb and first finger web space to increase or maintain the thenar
space and prevent contractures.