MODUL

HIP KNEE ANKLE FOOT ORTHOTICS

JURUSAN ORTOTIK PROSTETIK

POLTEKKES KEMENKES SURAKARTA
 Index

Chapter 1 - Functional anatomy of the hip 3

Chapter 2 - Pathologies related to the use of HKAFOs 6

Chapter 3 - Clinical Assessment of the Hip 20

Chapter 4 - HKAFO Components 25

Chapter 5 - HKAFO Fabrication and fitting 33

Chapter 6 - Fabrication of Pavlik harness 38

Acknowledgements and References 75

Page 2 of 41
 Functional anatomy of the hip.

Introduction of the Pelvic Girdle (Pelvis)

The pelvic girdle is made up of three separate bones, the two innominate
bones and the sacrum. The innominate bone is formed from three separate
bones, the ilium, ischium and pubis, which come together and fuse in the
region of the acetabulum so that in the adult the innominate appears as a
single bone.

Functions of Pelvis
I. It supports and protects the organs of the pelvic region.

II. It supports the weight of the body transmitted through the vertebrae,
through the sacrum, across the sacroiliac joints to the innominate
bones and then to the femur in standing position, or the ischial
tuberosities when sitting.

III. During walking the pelvis swings from side-to-side by a rotatory

movement at the lumbosacral articulation. Even if the hip joints are
fused, this swing of the pelvis enables a patient to walk.

IV. the pelvis provides attachments for muscle.

V. In the female it provides bony support for the reproductive organs

Page 3 of 41
 The Innominate (Hip) Bone

The irregularly shaped innominate consists of three bones fused

together: the ilium, the pubis and the ischium.

Iliac Crest
THE ILIUM
The ilium forms
the broad base for
the attachment of
ligaments and
large muscles of
the leg.

THE ISCHIUM
The ischium is the
posterior inferior
part of the
innominate.

THE PUBIS
Is found on the
anterior distal
aspect of the
innominate.

Obturator Foramen

The Innominate, Lateral View

The Femur
The upper end of the femur consists of a head, neck and the greater and lesser
trochanter.

Connecting the head to the shaft is the neck which is approximately 5 cm long
and forms an angle with the shaft of ~125°. This angle varies with age and sex.

The greater trochanter is situated on the lateral aspect of the upper part of the
shaft lateral to the neck. It is somewhat square shaped and rough due to the
muscle insertions upon it.

The lesser trochanter is conical in shape and situated medially, behind and
below the neck.

Page 4 of 41
 Coxa Vara:
The angle of the femoral
shaft and neck is less than 125o,
this can lead to problems with
ROM (particularly abduction and
internal rotation.)

Coxa Valga:
The angle of the femoral
shaft and neck is more than 125o,
this can lead to problems with
subluxation or dislocation as the
femoral head is pulled out of the
acetabulum. Commonly seen in
Cerebral Palsy.

Page 5 of 41
Muscles Around The Hip Joint
Hip extensors

Gluteus maximus
As its name implies, this is the largest of the gluteal muscles. It is very
powerful and is situated on the posterior aspect of the hip joint.

Superior articular Functional activity

facet Ilium
A powerful extensor of the
thigh, especially when the hip
is flexed. Used in powerful
movements such as stepping
up onto a stool, climbing and
running. It is not generally
used as an extensor in normal
walking.
Sacrotuberous
ligament rGluteal
tuberosity Gluteus maximus can be used
uperficial fibres(cut)
to produce a functional
for insertion into
iliotibial tract
extension of the knee in
patients whose quadriceps
are weak or paralyzed.

Nerve supply: Inferior gluteal nerve

Nerve root: L5, S1, S2

Paralysis of the Gluteus Maximus will lead to a flattening of the buttock and an
inability to climb stairs and run. However it must be kept in mind that there are
other muscles that can produce extension of the hip.

Hip Flexors

Psoas Major and Iliacus (Iliopsoas)

Psoas major is a large, thick powerful muscle
situated mainly in the abdominal cavity.

Functional activity
The action and functional activity of psoas and
iliacus are combined for hip flexion. Both are active in
lifting the trunk from a supine position.

Nerve supply and nerve roots

Iliacus: femoral nerve, L2, L3
Psoas major: anterior rami of L1, L2, L3 (sometimes
L4)

Page 6 of 41
Hip abductors

Gluteus medius
Gluteus medius is
Iliac crest situated on the lateral
Gluteus medius and upper part of the
buttock, just below the
iliac crest. It is fan-
Piriformis shaped and it fills the
Sacrum— Mr' space between the iliac
crest and the greater
Gemellus
superior trochanter of the femur.
Obturator
internus
Functional activity
Greater
Gemellus trochanter The gluteus medius
inferior plays a vital role in
Quad ratus -~ ------ ***Wi stance phase. When a
fern oris W\ Femur limb is taken off the
Adductor I'Tendinous part -4j
magnus \ Aponeurotic part -U y 1 *-V N v that side would tend to
drop, the Gluteus medius works to maintain, or even raise, the opposite side of
the pelvis. This allows the swinging leg to be brought forward for the next step.

If the muscle is unable to work efficiently due to paralysis or poor mechanics of

the hip joint, the pelvis will drop on the opposite side. This is referred to as a
Tendelenburg sign. Walking in this case is awkward and difficult, and running
virtually impossible.

Nerve supply: Superior gluteal nerve

Nerve root: L4, L5, S1
ground the pelvis on

Page 7 of 41
Hip adductors

Adductor
magnus
Adductor
brevis

Adductor
longus

Adductor
magnus

Adductor Magnus
Adductor magnus is the largest and most posterior of the group. The
muscle is really made up of two parts, an adductor part and a hamstring part.
The muscle is triangular in shape, due to it origin on the ischial tuberosity and
attachment along the shaft of the femur.
The muscle is an adductor of the hip joint, although the posterior portion will aid
in extension of the hip.

Nerve supply and nerve roots

Adductor part - Obturator nerve (posterior branch), L2, L3)
Hamstring part - sciatic nerve (tibial division), L4

Adductor Longus
Adductor longus is a long, slender, triangular
muscle, overlying the middle part of adductor
magnus.
It is an adductor of the thigh, and possibly a
rotator of the thigh. Due to its position in the
midline, Adductor longus can also flex the
extended thigh, and extend the flexed thigh.
Nerve supply: Obturator nerve (anterior
branch)
Nerve roots: L2, L3, L4

(Left) Right side adductor longus, (Right) Right side

adductor brevis, posterior view.

Page 8 of41
Adductor Brevis

Adductor brevis is again a triangular muscle situated on the medial

aspect of the thigh. It acts to adduct the thigh.

Nerve supply: Obturator nerve (anterior branch)

Nerve roots: L2, L3, L4

Summary of Muscle Activity of the Hip Joint

Hip Abductors
Hip Extensors
Gluteus medius
Gluteus maximus
Tensor fasciae latae
Gluteus medius & minimus
Gluteus minimus
Semimembranosus
Piriformis
Semitendinosus
Gluteus maximus
Adductor magnus
Biceps Femoris
Hip Adductors
Adductor magnus
Hip Flexors
Adductor longus & brevis
Iliopsoas
Gracilis
Rectus femoris
Semitendinosus
Sartorius
Gluteus maximus
Tensor fasciae latae
Pectineus

Hip Internal Rotators

Gluteus medius & minimus
Tensor fasciae latae
Adductor magnus, longus and brevis

Hip External Rotators

Gluteus maximus
Quadratus femoris
Obturatorius internus
Gluteus medius & minimus
Iliopsoas
Piriformis

Page 9 of 41
The Hip Joint
The hip joint is a ball and socket joint and is formed by the head of the femur
and the acetabulum of the innominate (pelvic) bone.

The acetabulum is a concavity formed from the Ilium, Ischium and Pubis. It
forms almost a half sphere of bone and is made more spherical by the addition
of a fibrocartilage lip- the Acetabular Labrum - around the perimeter.
A strong ligament runs from the center of the acetabulum to the femoral head -
ligamentum teres - this ligament helps stabilize the head of femur into the
acetabulum.

The head of the femur is slightly more than half a sphere, is entirely smooth
and covered with articular cartilage. There is a small hollow just below its
center, the fovea, which provides attachment for the ligament of the head of the
femur.

Page 10 of 41
Ligaments of the Hip Joint

Iliofemoral ligament ("Y ligament")

Reflected head of
rectus femoris The iliofemoral ligament is
Iliofemoral ligament very strong and thick, and lies
Upper band
across the anterior surface of
Lower band
the joint.

It is a triangular band with one

corner attaching to the
anterior inferior iliac spine and
the rim of the acetabulum,
with the base being a wide
attachment to the
intertrochanteric line.

However, because the central part is thinner it is often referred to as being Y-

shaped. This ligament resists extension of the hip joint and can be used to hold
the leg stable in an extended position, without the use of muscular actions.

Pubofemoral Ligament

Reflected head of
, rectus femoris The pubofemoral ligament strengthens
the inferior and anterior aspects of the
joint capsule.
Pubofemoral
ligament
It runs from the iliopubic eminence
and superior pubic ramus to the lower
Ar part of the intertrochanteric line,
blending with the iliofemoral ligament.
Reflected head of The ischiofemoral
rectus femoris
ligament is spiral in
shape.
Ischiofemoral
ligament
It arises from the body of
Posterior view the ischium behind and
Ischiofemoral Ligament below the acetabulum,
spiralling laterally and
upwards to attach to the
superior part of the neck
and root of the greater
trochanter.

Page 11 of 41
Movements and range of motion of the hip joint:
The hip joint is a synovial ball and socket joint with movement in all three
planes, the movements possible are:

Flexion: 120° (~90° when the knee is extended)

Extension: 30°

Abduction: 45 - 50°

Adduction: 20 - 30°

External Rotation: 90° (~45 ° when the hip is flexed)

Internal Rotation: 70° (~35° when the hip is flexed)

The minimum hip joint range of motion needed in order to carry out normal
daily activities are : Flexion: 120°
Abduction: 20°
External Rotation: 20°

Normal walking requires the following range of motion of the hip joint:
Flexion: 37°
Extension: 15°
Abduction: 7°
Adduction: 5°
Internal Rotation 4°
External Rotation: 9°

Anatomical position of the hip joint

The neck of the femur is angled anteriorly and superiorly with respect to the
Greater Trochanter. Which means that for adults the anatomical hip joint is
generally considered to be located:

1cm Anterior and 1 cm Superior to the Greater Trochanter.

Page 12 of 41
Pathology

The Pathologies related to the use of HKAFOs are usually quite debilitating. It
is probable that the use of a HKAFO will require more energy than the patient
has available. The question will be whether the patient will gain any benefit
from the use of the device, or whether they would be better off with other
treatment.

A compromise solution may be the best for patients requiring a HKAFO. Ie. the
use of a wheelchair for mobility, but the use of a HKAFO for standing,
transferring and walking short distances.
Eg. The patient uses a wheelchair to travel to school, but the classroom has no
space for the wheelchair. The patient can then get out of the wheelchair and
walk inside to the classroom.

Generally treatment is most successful for children because they are smaller
and more energetic, and because parents tell the child that they "must" use the
device. The effort needed may be slightly higher in adults, and they are more
likely to discard the device on the grounds of comfort or cosmesis.

In all cases when a HKAFO is considered, it is very important to asses the

advantages for the patient and compare carefully to the disadvantages of
weight, energy consumption, cosmesis, etc.

The following gives a brief description of the treatment of the most common
pathologies requiring a HKAFO:

Page 13 of 41
Congenital dislocation of the hip
This condition is seen at birth and is a dislocation of the head of femur from the
acetabulum usually in a superior / posterior direction. There are various
degrees of "dislocation" including
- Hip joint laxity - an abnormal increase in joint mobility because of
stretched capsule, muscle and/or ligaments.
- Subluxation - the femoral head is sitting on the edge of the acetabulum,
it is not completely out of the joint, but appears that it could easily come
out.
- Dislocation - the head of the femur is completely out of the acetabulum
and commonly has moved superior and posterior (due to the pull of the
hip musculature).

Another term used with CDH is developmental dysplasia of the hip (DDH)
which also includes hips that are normal at birth but develop abnormally after
birth.

Many children have slight laxity of the hip joint at birth, but about 60% will
resolve within the first few weeks. Girls are generally more affected than boys,
and the left hip more often than the right. It is believed that the hormones
released by the mother prior to childbirth (relaxin) affects female children more,
producing "loose" tissues.

An X-ray film is showing a

case of CDH on the right hip
joint. (The left side of the X-
ray).

The reasons for dislocation of the hip are unknown but certain factors are
thought to affect the condition, these are:
1) Ligament laxity
2) Shallow or malformed acetabulum
3) Genetic influence
4) Position of the fetus in the uterus
5) Environmental factors (e.g. wrapping the baby tightly in a
blanket)

CDH is often seen in children with other disabilities:

- Down's Syndrome
- Spina Bifida
- Arthrogryposis
- Clubfoot
- C.P.

Page 14 of 41
With systematic examination of newborn children, CDH can easily be detected
and treated. This is because the patient has not yet begun to stand and walk,
so no large forces need to be transferred between the bones. Another
advantage to early detection is that the ligaments and tissues are still flexible in
a newborn, so if the problem is corrected the tissues can quickly adjust and will
grow in the correct way.

If the condition is detected after the child has begun standing / walking,
treatment becomes more complicated and lengthy. This is because the tissues
will have contracted and the forces will have damaged the head of the femur
and possibly the acetabulum / pelvis.

Diagnosis and treatment of congenital dislocation of the hip:

Treatment and diagnosis varies for different age groups. The common aim is to
restore the head of the femur into the acetabulum and then hold it in place so
that the tissues have a chance to heal in a correct position.

The Ortolani test is commonly used to diagnose

CDH in infants.
The child is laid down in supine and both femurs
are flexed and adducted, so that the legs touch
each other.

The examiner then slowly abducts them until

resistance is felt. This should be at 90°
abduction. If the hip ligaments are loose or the
hip is dislocated a "click" will be felt or heard as
the legs are abducted, and the head of the
femur drops back into the acetabulum.

If it is not possible to achieve the full ROM it is

likely that the hip is dislocated.

The Barlow Test is performed in a similar manner, but is intended to test the
possibility that the hips will sublux. The aim is to get the femur to move out of
the acetabulum. The infant is supine with hips and knees flexed 90 degrees,
and abducted fully. The examiner then moves the legs toward each other until

Page 15 of 41
knees and ankles touch, all the while pushing slightly posterior. An unstable hip
may be felt to move out of the acetabulum.

Early infancy (0 - 3 months):

Treatment at this early stage will generally be of ~3 months duration. The hip is
held by an orthoses (or POP cast) in 90 degrees flexion and 45 degrees
abduction from the midline. This will locate the femoral head in the acetabulum.
The treatment will allow the ligaments and joint capsule to tighten around the
joint, and hopefully make it stable. It is important that an X-ray is taken with the
orthosis in place, so as to confirm the correct position of the hip joint.
There are many different orthoses available for this treatment, all have slightly
different application and adjustment features. The more successful devices are
designed so that they do not need to be removed to feed, change or clean the
infant. An orthoses which has to be removed for cleaning / caring of the child
will often tempt the parents to leave it off "until next time".
V
o
n

R
o
s
e
n
'
s

s
p Pavlik harness
l (Incorrectly
i applied)
nt

Late infancy (3-18 months):

The signs / tests for CDH at this stage are as follows:
1) Apparent shortening of the involved limb, when the limb is held in
slight flexion and external rotation of the hip.
2) Limited passive hip abduction ( Hip adduction contracture)
3) Galeazzi's sign - with the patient supine, hips and knee flexed and
feet tucked close to the buttocks, the knee of the affected side
appears lower than that of the sound limb.
4) X-rays will show abnormal development of the acetabulum and
delayed ossification of the femoral head.
5) When standing or lying in supine the affected leg appears shorter
and is held in external rotation.

Treatment of this age group is lengthy - on average 6-18 months - and is often
accompanied by minor surgery such as an adductor release or adductor
stretching. Surgery will usually be followed by a period in a plaster cast and
then orthotic use.

Page 16 of 41
 Advanced dislocation (18 months and older):

The older CDH patient may present with a positive Trendelenburg sign. This is
because the hip dislocation causes the Gluteus Medius muscle to be ineffective
in keeping the pelvis level during single stance on the affected side.
Conservative orthotic treatment is usually not effective at this stage and surgery
is needed. The surgery includes muscle releases, open reduction, pinning and
reconstruction of the acetabulum (by taking bone from the Iliac crest and
placing it proximal and posterior around the joint).

Orthoses for Congenital Dislocation of the Hip

Pavlik Harness
Pavlik introduced this harness in 1945. In 1957, he published his results for the
treatment of nearly 1912 hips. His original harness was fabricated with leather.
Since that time, the harness has achieved widespread use and acceptance,
and numerous commercially constructed versions have become available.
The harness is used in infants up to 12 months but has had higher success
rates at younger ages. The Pavlik harness consists of a
chest strap positioned at the nipple line, with halter
straps that should cross in the back to prevent slipping.
The anterior / flexor straps should be at the anterior
axillary line; if more medial, they produce an adduction
force. These should be tightened to maintain the hips at
90o flexion
The posterior straps should overlie the scapula and be
tight enough to prevent adduction.
The leg straps should not impinge in the popliteal fossa.
A retaining strap just inferior to the popliteal fossa is
necessary to prevent the medial flexion straps from
moving laterally, creating an adduction force.

Page 17 of 41
Technique of Application:

Taken from: www.wheelessonline.com/ortho/pavlik_harness

The harness is applied with the child supine.

Chest straps: The chest strap is applied first, allowing enough room for hand to
be placed between the chest and the harness.

Shoulder straps: The shoulder straps are buckled to maintain chest straps at
nipple line.

Stirrups: Feet are placed in the stirrups one at a time. Socks may be worn
under the straps if they cause abrasions.

Anterior leg strap: The hip is flexed (90 to 120 deg), and the anterior flexion
strap is tightened to maintain this position. (Femoral nerve palsy has been
reported w/ hip flexion greater than 120 deg.)

Posterior leg strap: The posterior strap is loosely fastened to limit adduction,
not to force abduction. The knees should be 3-5 cm apart at full adduction in
harness.

DO NOT cut any straps - straps may have long "tails" but these may be
needed as the child grows.

The properly applied harness should still allow some movement of the baby,
but should restrict movements leading to subluxation (extension and adduction).

Treatment with Pavlik harness

Once the child has been placed in the harness, an X-ray should be taken to
ensure reduction has been obtained. If it has not, the radiograph serves for
future comparison. Sometimes the hip may not be immediately corrected, but
will reduce with time as ligaments and muscles adjust to the correct position.
If after 2 weeks no correction has been obtained, an adductor tenotomy may be
indicated. It is not advisable to continue Pavlik treatment, if correction cannot
be obtained by 3 weeks with or without adductor tenotomy. Long term harness
treatment in an irreduceble hip may permanently erode the posterior acetabular
rim.
Once reduction has been confirmed, a weekly physical examination allows the
clinician to ascertain the stability of the hips, adjust for growth of the child,
maintain rapport, and ensure parental education in the use of the orthosis.
Periodic radiographs (every 4 to 6 weeks) are recommended to document
maintenance of reduction.

Length of treatment
There are currently no available tables or values for length of treatment. It is
recommended that treatment be full time until stability is obtained, then
continued for 6 weeks before beginning a weaning period.

Page 18 of 41
 Incorrectly applied harness. The hip is
hyperflexed because of tightening of the
anterior straps. This position can lead to
femoral nerve palsy. The hip should be
positioned at 90 -120 degrees of flexion.

Page 19 of 41
Ilfeld Orthosis

The Ilfeld orthosis is primarily an abduction

orthosis. It promotes flexion to some degree.
It differs markedly from the Pavlik harness in
that it is a passive device and does not allow
motion of the hip joint. It is made with two
thigh cuffs and an adjustable metal crossbar
that allows variation of abduction.
Suspension is through a waist strap, which
can provide some flexion of the hips.
It is an effective postoperative or postcast
treatment to aid in maintaining abduction. It
also functions well after Pavlik harness treatment in older and larger children
and as a night splint to maintain abduction for a portion of the 24-hour cycle. It
is not as popular as the Palvik harness for the primary treatment of CDH.

Von Rosen orthosis

In 1962, Von Rosen reported his use of a special splint

in the treatment of 39 cases of congenital hip
dislocations (CDH)
The Von Rosen orthosis, similar to the Ilfeld orthosis, is
a passive motion restraint, being adjustable in both
abduction and flexion. It was originally fabricated from
malleable aluminium with a plastic covering. Today the
orthosis is made of malleable plastic with three sets of
flaps for the shoulders, waist, and thighs. Straps for
security of fixation have also been added. Although the
Von Rosen orthosis has not found significant use in
North America, it is still prevalent in parts of the
Scandinavian orthopedic
community.

Page 20 of 41
Frejka Pillow

The Frejka pillow is an adaption of a common

mid-wife / community nurse technique to
produce abduction and flexion of the hip - the
use of multiple diapers.
Frejka was one of Pavlik's professors. Both
physicians were concerned that previous
methods of CDH treatment had unacceptably
high rates of avascular necrosis. In 1947,
Frejka created the pillow after experiencing
some success with abduction treatment. It was
noted, however, that a child could overcome
the soft pillow and was not reliably maintained
in abduction. This also helped to stimulate
Pavlik to invent his harness. Another notable
drawback was that the Frejka pillow did not
provide enough flexion.

Subluxation of the hip

Subluxation is when the femoral head is not fully seated in the
acetabulum. It may follow unsuccessful treatment of
congenital dislocation or it may be an incomplete form of
dislocation.

Management
In the infant, treatment is similar to that for dislocation; the hip
is held in abduction until the acetabular roof looks normal. In
children more than a year old an operation may be needed to
re-model the joint.

Page 21 of 41
Legg - Calve - Perthes Disease (Necrosis of the femoral head):
This condition has been described by numerous surgeons and is known by
many names. The main feature of this condition is that the blood flow to the
femoral head is interrupted and the
bone cells die. It is usually caused
by trauma, but some cases appear
to lack any trauma.
The three stages are thought to be:
1) Necrosis (avascularisation) -
lack of blood to femoral head
and death of the bone.
2) Re - vascularisation - blood
supply returns.
3) Healing phase - the bone
slowly regenerates.
If the patient is weight bearing during the third phase, the head of the femur
does not reform correctly, often ending up flattened. In the long term this results
in excessive forces in the joint and a breakdown of the cartilage leading to
arthritis, pain and lack of mobility.

The condition is 4 - 6 times more common in boys, and usually seen between
4 and 8 years of age.

Treatment
The aim of treatment is to prevent deformity of the femoral head. This is done
by positioning the head centrally in the acetabulum, and reducing movement.

The devices pictured below allow the patient to move around while maintaining
the head of the femur in the correct position. The device on the right also
utilises Ischial weight bearing, and thus aims to unload the lower limb
completely.

There is some controversy regarding the use of Ischial Weight Bearing for
treating this condition, as some argue that the action of the hip abductor
muscles will cause deformation of the femoral head.

Page 22 of 41
Fracture of the femoral neck
This injury occurs as a result of trauma. It is seen mainly among elderly women
whose bones are osteoporotic. The patient may fall, but often merely catches
her foot and twists the hip; the femoral neck is broken with the rotational force.
In most cases the fracture is displaced and completely unstable. In some, the
fragments are impacted and the patient may even walk about, albeit with some
pain.

Complications
Avascular necrosis - There is a high incidence of avascular necrosis in
fractures of the hip. The femoral head derives its blood supply from three
sources: the nutrient artery (3), vessels reflected from the capsule (2), and
vessels in the ligamentum teres (1)

Blood supply to the femoral head:

(1) a vessel in the ligamentum teres,
(2) the retinacular vessels
(3) the nutrient artery

When the femoral neck is fractured and severely

displaced, the branches from the nutrient artery are
severed, the vessels from the capsule are torn, and
the remaining blood supply via the ligamentum teres
may be insufficient to prevent ischaemia of the
femoral head. The bone dies and eventually
collapses, with distortion of the femoral head and irreversible damage to the
joint.

Treatment
Operative treatment is the standard procedure, as little
else can be done to stabilise the fracture. Displaced
fractures will not unite without internal fixation, and even
simple fractures would require the entire limb to be
immobilised. As most patients are elderly, the
detrimental health effects of staying in bed for the time
required to heal would lead most to have lung problems
and bed sores.
The benefits of internal fixation are that the fracture can
be placed in an ideal alignment and the patient can be
standing and walking within a short time.

Page 23 of 41
When the bone has been severely
damaged and cannot be repaired
using internal fixation a "hip
replacement" is done. The head
and neck of the femur are
removed and an internal
prosthesis used. The prosthesis
fits inside the medullary canal of
the femur and as the bone heals it
bonds to the prosthesis.

From the first postoperative day the patient should sit up in bed or in a chair.
They are encouraged to begin walking with HO and crutches as soon as
possible. The HO is designed to keep the hip in an abducted position, and
usually limits the range of flexion and extension as well.

Fractures in children are uncommon and are usually a result of direct trauma.
If the fracture is undisplaced it can be held in a plaster cast until it heals. If it is
displaced it should be reduced and fixed with threaded pins or screws.
Slipped upper femoral epiphysis

Displacement of the proximal femoral epiphysis is uncommon and usually

confined to children going through the pubertal growth spurt. Boys are affected
more often than girls.

Clinical features
The patient presents with pain in the groin, the anterior part of the thigh or the
knee (referred pain), and may also limp. On an X-ray a line drawn along the
superior surface of the neck remains superior to the head instead of passing
through it (Trethowan's sign). In the lateral view the femoral epiphysis is tilted
backwards

Complications
Avascular necrosis is the most serious complication. It is seen only after a slip
has been reduced or pinned, and is presumably due to the vessels being
damaged.
Coxa vara may result if the displacement is not reduced and the epiphysis
fuses in its deformed position. The patient limps but the condition is usually
painless. Osteotomy may be needed to correct the deformity and aid in
preventing secondary osteoarthritis.

Treatment
Surgery is required to re-attach the epiphysis. Post-operative treatment will
include the use of an orthosis to protect the epiphysis / in case of Avascular
Necrosis of the Femoral head.

Page 25 of 41
 Osteoarthritis

Osteoarthritis may develop in a relatively young adult following congenital

subluxation, Perthes' disease, coxa vara, acetabular deformities or injury. In the
older patient it may also be secondary to age related changes or trauma. When
no underlying cause is discovered it is referred to as primary osteoarthritis.

Pain is felt in the groin or hip but may radiate to the knee. Typically it occurs
after periods of activity but later it is more constant and sometimes disturbs
sleep. Stiffness is noticed chiefly after rest; later it increases progressively until
putting on socks and shoes becomes difficult. A limp is often noticed early and,
if the hip is adducted, the patient may think the leg is getting shorter.

On X-ray, the earliest sign is a decreased joint space, usually maximal in the
superior weight-bearing region but sometimes affecting the entire joint. Later
signs are subarticular sclerosis, cyst formation and osteophytes

Osteoarthritis - Progression over 4 years.

Treatment
Pain killers and anti-inflammatory drugs may be helpful, and warmth is soothing.
The patient is encouraged to use a walking stick and to try to preserve
movement and stability by non-weight-bearing exercises.

The use of an orthosis to keep the joint warm may be possible, and usually this
type of device will be made of and elasticated rubber type material (neoprene).
If the hip is to be relieved of all weight an IWBKAFO may be indicated.

Post Polio Paralysis

The clinical presentation of polio is described in greater detail in the K.A.F.O
manual. A hip joint and rigid pelvic band can be used in the case where the
patient has poor control of the muscles controlling the hip joint, for example in
cases where rotational control is lacking.
If the patient is lacking hip abductor strength a rigid pelvic band will not provide
enough surface area to distribute the forces needed. In this case a Lumbar
Sacral section needs to be attached and the leg kept in adduction.

Page 26 of 41
Spinal cord injuries
Injuries above T 12 can be treated with HKAFOs(combined with body jacket) in
order to have the patient standing so that balance can be trained and blood
circulation improved. However the energy requirements of such walking are
very high.
It is likely that patients with injuries above T12 will find a wheelchair much more
functional. However, the psychological and physiological benefit of standing
cannot be ignored. Being able to stand, and even walk short distances, can
improve the physical well being of the patient.

Cerebral Palsy
A HKAFO that blocks / controls movement at all the joints will be very difficult
for a person with CP to use. The most common usage is with "twister cables"
designed to correct spastic internal rotation of the hip. Twister cables which are
attached to a pelvic band and connected to an A.F.O. or the shoe resist the
rotation. This enables the patient to swing the leg through in a straight line
when walking.

Spina Bifida
The use of HKAFOs for Spina Bifida are very similar to that of other patients
with a spinal cord injury. Young patients with L1- L3 lesions can use HKAFOs
to assist in walking very short distances and for transfers.
Generally patients with L3 lesions and higher will be non-walkers and T12
lesions will be wheelchair bound.

Page 27 of 41
Clinical Assessment of the Hip
The patient assessment is the most crucial part of the whole process. The
Orthotist must conduct both a subjective and objective examination of the
patient.

Subjective and Objective Assessment

The subjective examination involves questioning the patient about his / her
condition including the main complaint, the way they got hurt, effects of
previous treatment, patient goals, patient concerns/questions. The subjective
assessment should include factors not directly related to the condition,
including employment, living conditions, mental status and distance from the
centre. This gives the Orthotist an understanding of how the patient sees
his/her problem and how possible solutions may impact upon the life of the
patient and family.

The objective assessment involves a series of tests to evaluate the

neurological and musculoskeletal status of the patient. These include gait
assessment, range of motion, muscle strength, sensation, edema, etc.
Examination of whole the body is required to gain a complete picture of all the
problems the patient may have.

The Oxford Muscle scale is used to measure Muscle strength and standardized
tests are used to measure ROM.

Hip Flexors

Grade 3, 4, and 5
Position of Patient: sitting with thighs fully supported on table and legs
hanging over the edge. Patient may use arms to provide trunk stability by
grasping table edge or with hands on table at each side

Test: Patient flexes hip, lifting the thigh from the table while maintaining neutral
rotation.

Instruction to patient" "Lift your leg off the table and don't let me push it
down."

Page 28 of 41
Grade 2, 1 and 0
Position of patient: Side-lying with limb to be tested uppermost and
supported by examiner with one hand under the knee and one hand one the
hip to maintain stability and feel for muscle actions. Trunk in neutral alignment.
Lowermost limb may be flexed for stability.

Test: Patient tries to flex hip, bringing the lower limb toward anterior.

Instruction to patient: "Try to bring your knee up to your nose / toward your
chest."

Substitutions - be careful that you patient isn't doing the following!

• Use of the Sartorius will result in external rotation and abduction of the hip.
The Sartorius, because it is superficial, will be seen and can be palpated
in most limbs.
• If the tensor fasciae latae substitutes for the hip flexors, internal rotation
and abduction of the hip will result. If, however, the patient is tested in
the supine position, gravity will cause the limb to externally rotate.

Hip Extensors - all

Grade 5, 4 and 3
Position of Patient: Prone. Arms may be overhead or abducted to hold sides
of table. (Note: if there is a hip flexion contracture, immediately go to the test
described for hip extension modified for hip flexion tightness

Alternate Position: The hand that gives resistance is placed on the posterior
thigh just above the knee. This is a less demanding test.

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Test : Patient extends hip through entire available range of motion. Resistance
is given straight downward toward the floor.

Instruction to patient: "Lift your leg off the table as high as you can without
bending your knee."

Grade 2, 1, 0
Position of Patient : Side-lying with test limb
uppermost. Knee straight and supported by /T\
examiner. Lowermost limb is flexed for stability.

Test: Patient extends hip thorough available range

of motion

Instruction to Patient: "bring your leg back toward

me. Keep your knee straight."

HIP EXTENTION TEST TO ISOLATE GLUTEUS MAXIMUS

Grade 5, 4 and 3

Position of Patient: Prone with knee flexed to 90 (Note: in the presence of a

hip flexion contracture, do not use this test but refer to the test for hip extension
modified for hip extension modified for hip flexion tightness.

Test: Patient extends hip through available range, maintaining knee flexion.
Resistance is given in a straight downward direction (toward floor).

Instruction to Patient: "Lift your foot to the ceiling" OR "Lift your leg keeping
your knee bent."

Page 30 of 41
Grade 2, 1, 0
Position of Patient: Side-lying with test limb
uppermost. Knee is flexed and supported by
examiner lowermost hip and knee should be
flexed for stability.

Test: Patient extends hip with supported knee

flexed.

Instructions to Patient: "Move your leg back

toward me."

HIP EXTENSION TESTS MODIFIED FOR HIP FLEXION TIGHTNESS

Grade 5, 4 and 3

Position of Patient: Patient stands with hips

flexed and places torso prone on the table.
The arms are used to "Hug" the table for
support. The knee of the non test limb should
be flexed to allow test limb to rest on the floor
at start of the test.

Test: Patient extends hip through available

range. Keeping the knee in extension will test
all hip extensor muscles, with the knee flexed
the isolated Gluteus maximus will be
evaluated.
Resistance is applied downward.

Instruction to Patient: "Lift your foot off the

floor as high as you can".

Grade 2, 1, 0
Do not test a patient with hip flexion contractures and weak extensors in the
standing position. Position the patient side-lying on the table.

Hip Abductors
Grade 5, 4 and 3

Position of Patient: Side-lying with test leg

uppermost. Start test with the limb slightly
extended beyond the midline and the pelvis
rotated slightly forward. Lowermost leg is flexed
for stability.

Page 31 of 41
To distinguish a grade 5 from a Grade 4 result, first apply resistance at the
ankle and then at the knee.

Test: Patient abducts hip through the available range of motion without flexing
the hip or rotating it in either direction. Resistance is given in a downward
direction.

Instruction to Patient: "Lift your leg up in the air. Hold it. Don't let me push it
down."

Grade 2, 1, 0
Position of patient: Supine, with the tester
supporting the limb under the ankle. The
limb should be raised just enough to
reduce friction with the surface. The tester
should offer no resistance, nor aid the
movement.

Test: Patient abducts hip through available

range.

Instruction to Patient: "Bring your leg out

to the side. Keep your kneecap pointing to
the ceiling."

Substitutions - be careful that you patient isn't doing the following!

Hip-hike substitution: Patient may "Hip Hike" by
tilting the pelvis using the lateral trunk muscles,
which moves the limb through partial abduction
range. This movement may be detected by
observing the lateral trunk and hip and palpating
the Gluteus medius above the trochanter.

External rotation and flexion substitution:

the patient may try to externally rotate
during abduction. This could allow the
oblique action of the hip flexors to substitute
for the Gluteus medius.

• Tensor fasciae latae substitution: if the test is

Allowed to begin with active hip flexion or with the hip positioned in
flexion, there is an opportunity for the tensor fasciae latae to abduct the
hip.

Page 32 of 41
Hip Adductors
Grade 5, 4 and 3
Position of patient: Side-lying with test limb (lowermost) resting on the table.
Uppermost limb (non test limb) abducted, supported by the examiner. The
therapist cradles the leg with the forearm, the hand supporting the limb on the
medial surface of the knee.

Test: Patient adducts hip until the lower limb contacts the upper one.

Instruction to patient: "Lift your bottom leg up to your top one. Hold it. Don't
let me push it down."
For grade 3:"Lift your bottom leg up to your top one. Don't let it drop!"

Grade 2, 1, 0
Position of Patient: Supine. The non test
limb is positioned in some abduction to
prevent interference with motion of the test
limb. The tester supports the ankle and
elevates it slightly form the table surface to
decrease friction. The examiner uses this
hand neither to assist nor resist motion, the
opposite hand palpates the adductor mass
on the inner aspect of the proximal thigh.

Position of Therapist: Standing at side of

test limb at knee level.

Test: Patient adducts hip without rotation.

Instruction to patient: "Bring your leg in

toward the other one".

Substitutions - be careful that you patient isn't doing the following!

• Hip flexor substitution: the patient may attempt to substitute the hip
flexors for adductors by internally rotating the hip using a posterior pelvic
tilt. The patient will appear to be trying to turn supine from side-lying.
Maintenance of true side-lying is necessary for an accurate test.

• Hamstring substitution: Patient may attempt to substitute the hamstrings

for the adductors by externally rotating the test hip with an anterior pelvic

Page 33 of 41
 tilt. Patient will appear to move toward prone. Again true side-lying is
important.

External Rotators
Grade 5, 4 and 3
Position of Patient: Sitting. Arms may be used for trunk support at sides or
may be crossed over chest.

Test: Patient externally rotates the hip. This is a test where it is preferable for
the examiner to place the limb in the test end position rather than to ask the
patient to perform the movement.

Instruction to patient: "Don't let me turn your leg out"

Grade 2 , 1 , 0
Position of Patient: Supine. Test limb is
in internal rotation.

Test: Patient externally rotates hip in

available range of motion. One hand
may be used to maintain pelvic
alignment at lateral hip.

Instruction to patient: "Roll your leg

out."
Internal Rotators
Grade 5, 4 and 3
Position of Patient: Sitting. Arms may be used
for trunk support at sides or
may be crossed over chest.

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Test: The patient internally rotates the limb. The limb should be placed in the
end position of full internal rotation and then force applied towards external
rotation.

Instruction to patient: "Don't let me turn your leg in"

Grade 2, 1, 0
Position of Patient: Supine. Test limb in
external rotation.

Test: Patient internally rotates hip through

available range.

Instruction to the patient: "Roll your leg

in toward the other one"

Page 35 of 41
Thomas Test

Position of Patient: Supine with level pelvis.

Test: To test for hip flexion contractures, place your hand under the lumbar
spine and flex the hip. Feel for when the spine flattens. Raise the other leg so
that they are both to the chest. Lower one leg to the table. If the leg does not
extend fully or the patient rocks forward or arches their back then they have a
hip flexion contracture. You can then measure the contracture by examining the
angle between the thigh and the table.
Instruction to the patient: "Hold one leg to your chest and let the other one
lower to the table"

The Trendelenburg test

Position of Patient: standing

Trendelenburg test is a simple maneuver to evaluate the strength of the gluteus

medius and gluteus minimus muscle. It is performed by having the patient stand
unassisted on one leg while the other leg is raised off the ground. The examiner places
their fingers on the posterior ilaic spine. If there is a significant drop of the hip on the
side of the raised leg

Positive Trendelenburg Test with

Weakness of left hip abductor
Muscles

Page 36 of 41
HKAFO COMPONENTS

HIP JOINTS If there is no need to control

Most hip joints have a single axis
permitting flexion and extension and
include adjustable stop to limit
hyper extension (figure A). By
nature of their design, these joint
also prevent abduction-adduction
and rotation. The flexion and
extension capability can
restricted by including a pawl or
drop lock similar to those used at
knee joints. (figure B).
abduction-adduction, a double axis
joint my be used (figure D) the
flexion extension may be lock as
required, while the abduction-
adduction axis includes adjustable
stop to place limits on these
motions as needed.
be

Two position hip locks which

provide locking for both at full
extension and at 90 degrees of hip
flexion (figure C), are particularly
useful for individual who have
difficulty maintaining the sitting
position because of spasticity of the
hip musculature.

THE PELVIC BAND

The Pelvic band is usually made out of aluminum, but both steel and
Polypropylene are possible materials.

The anterior end of the band lies just anterior to the lateral midline of the pelvis,
in the middle between the iliac crest and greater trochanter.

The band then curves posterior and down to correspond as good as possible
with the height of the hip joint axis.

For the shape of the pelvic band, a lead strip or similar can be used to obtain
the shape of the pelvis. Trace the shape made with the strip onto paper and
contour the pelvic band accordingly.

Anterior of the band is a soft leather belt with padding.

Page 37 of 41
The pelvis band and the KAFO should not be assembled before during first
fitting

HKAFO Fabrication and Fitting

Fabrication
The measurements and tracing for HKAFO Production are the same as for
KAFO (See KAFO Manual pg 50) plus:

1. Distance Knee Center - Hip Center

2. Distance Hip Center - Center Pelvis band.
3. Circumference at Center Pelvis band
4. Diameter at Center Pelvis band

Alignment:

Lateral plumb-line: from GT over BoS (between medial malleolus and navicular

Coronal plane: slightly adducted

Mechanical axis of hip joint

Frontal plane

Normally, the flexion and extension axes of the hip are essentially
perpendicular to line of progression

If bilateral hip joints are used both axis should be the same level

Sagittal plane

Similar to trans femoral prosthesis mechanical axis of hip joint is located about
1 cm posterior and one cm superior to greater trochanter.

Page 38 of 41
Transverse plane

Normally, place parallel to the axis of knee joint

Fitting of the HKAFO

Fitting of the HKAFO follows the same process as fitting the KAFO (see KAFO
Manual pp 48 & 59). Additional steps are as follows:

Contour hip joint to fit the tracing and attach to KAFO section.

Pelvic band should be aligned and attached at initial fitting.

Fit the KAFO section to the patient and ensure hip joint axis is superior
and anterior to greater trochanter.

Place pelvic band in desired position and tighten anterior belt.

Ensure leg is in desired alignment and mark position of hip joint upright
on pelvic band.

In standing and/or walking check fit and function as you would for a
KAFO ensuring pelvic band fits closely against the pelvis and the hip
joints are correctly aligned.

Page 39 of 41
FABRICATION OF THE PAVLIK HARNESS
The measurements and design of the pavlik harness can be done by either
tracing the patient and taking measurements or just by using measurements
obtaining directly from the patient.

1. Mark the following areas on the patient

Posterior aspect of right ankle at the superior end of calcaneus and 2.5cm
above.
Lateral surface of right leg, 1.5cm below the distal tip of the head of fibula and
2.5cm distal.
Chest 1.5cm distal to the nipple line and 3cm distal to this mark
2.5cm distal to the inferior angle of the right scapula and 3cm distal to this.

2. Measurements
With hips slightly abducted and
knees flexed measure:
-Circumference of ankle, calf and
chest between the lines drawn
-Height from plantar surface of foot
to proximal marks for straps.
-Shoulder straps length: from 2.5cm
below left scapula at inferior angle
over right shoulder to 2.5cm below
and slightly lateral to the right nipple.

Strap fabrication
Thoracic strap: length = chest circumference plus
7.5cm
Width = 3cm
Shoulder strap: length = distance measured plus 7.5cm
Width = 1cm
Leg stirrups: length = distance measured from plantar surface of foot to distal
nipple plus 25cm
Width = 2.5cm
Ankle straps: length = ankle circumference plus 7.5cm
Width = 2.5cm
Calf straps: length = calf circumference plus 15cm
Width = 2.5cm

Page 40 of 41
References

CSPO manual, Lower extremity orthotics H.K.A.F.O 1994

Lower-limb orthotics, Prosthetics and orthotics New York University-Post

graduate medical school, 1986

England, Fannin, Skahan & Smith. (1977) A manual of lower extremity orthotics.
Charles C. Thomas: Publisher USA.

Goldberg and Hsu (1997) Atlas of orthoses and assistive devices Ed 3.

American Academy of Orthopaedic Surgeons

Hoppenfeld (1976). Physical Examination of the spine and its extremities.

Appleton Century Crofts New York.

McRae (1990) Clinical Orthopaedic Examination 3rd Ed.

Palastanga, Field, Soames (1989) Anatomy and Human Movement - Structure

and Function Butterworth-Heinemann 1989

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