Orthotic Written Simulation Study Guide

Scenario

A 5-year-old male patient and his mom comes in to your office for evaluation for bilateral orthotics. The patient has been diagnosed with myelodysplasia at level L4. The mom states that the patient has been undergoing OT/PT and is going to begin kindergarten in the fall.

Part A

You begin your evaluation:

A. Ask about allergies
B. Take height and weight
C. Inspect patients skin
D. Check the patients ROM/MMT
E. Have the patient ambulate between the parallel bars with a gait belt donned
F. Check the patients tone
Part B
Your evaluation finds the following answers:

A – The patient has a latex allergy
B – Ht: 44” Wt: 41lbs.
C- No signs of skin breakdown or concerns but mom states that patients skin is sensitive to pressure
D – Bilateral ROM – WNL bilaterally Bilateral MMT – Hip flexion/extension – 5/5, Knee flexion – 4-/5, knee extension 3-/5, DF 1/5, PF 2/5, Inv/Ev – 2/5
E – Patient presents with crouch gait and foot drop in swing phase, and a hindfoot varus deformity throughout stance phase bilaterally.
F- Mild spastic response with quick stretch

Now that your evaluation is complete, you formulate your treatment plan.

A. Custom single upright thermoplastic KAFOs
B. Single axis knee joints
C. Locking knee joints
D. Oklahoma ankle joints
E. Klenzak joints
F. UCBL style trim footplate
G. Custom semi-solid AFOs
H. Custom articulated AFOs
I. Custom GRAFOs
J. Molded inner boot
K. Full length footplate
L. Met length footplate
M. Sulcus length footplate
N. Soft interface

Part C
The patient comes in for a fitting of his custom made GRAFO with molded inner boot and soft interface. The patient ambulates in the brace and complains of pain along his patella, discomfort along the inside of his foot, and a slight valgum deformity that worsens at midstance. How will you address these issues?

A. Tell the patient’s mom that if he follows the break-in schedule, the areas of pain will go away
B. Evaluate the fit of the orthotic
C. Check the patient’s skin for signs of redness
D. Add a lateral heel wedge
E. Add a medial heel wedge
F. Bring the trimline of the GRAFO below the tibial tubercle
G. Heat and relieve along the patella
H. Add more padding to the entire molded inner boot to decrease skin breakdown

Answers

Part A – Correct Selections – A, B, C, D, E, F
Part B – Correct Selections – I, J, K, N

*Note – depending on whatever orthotic you select in this section, it will lead you down a different path. The “correct selections” in this Part are based off what is the best answer, though other options are potentially also partly correct.

Incorrect Selections:
A, B, C, D, E, F – Because the patient is so young, the goal is to avoid over bracing. Furthermore, none of these options would address the crouch gait except the locking knee joints, and that would be uncessary bracing for this patient. Both the Oklahoma and Klenzak joints would only further promote the crouch gait.

G – While this a viable answer, it would not be the optimal way to address the crouch gait and weakened knee muscles because a semi-solid AFO comes posterior to the malleoli and would likely hold up to the amount of stress that would be applied – if it was a solid AFO, this would potentially be a good answer
H – Potential problem with the articulated would be the spastic response while ambulating that could lead to skin breakdown and cause difficulty while walking. It also would not address crouch gait
L/M – These lengths are not recommended for patients with tone, and it is not the correct length footplate length for a GRAFO.

Part C – Correct Selections – B, C, E, G

Incorrect Selections –
A – While some discomforts may go away after a break-in schedule, if he is already complaining of pain, it is important to check his skin for redness and breakdowns that are already happening
D – A lateral heel wedge increases the pain along the inside of his foot and the valgum deformity
F – This will compromise the effectiveness of the GRAFO and may lead to increased pressure along the tibia