strapping boy .... RESPONSES

strapping boy .... RESPONSES

1 PLUS 1 Orthotics

3/6/1998

From
Vivian and Michael Alexander
1 PLUS 1 Orthotics


Dear Colleagues

we would like to thank all the people that have answer us - your quick
responses were of great help.

We have asked:

I am treating a little eleven month old boy .The boy was diagnosed as
having relatively short achilles tendons and AFO’s were recommended by
his orthopedic surgeon
The orthoses were made at 5 degrees dorsiflexion as requested by the
doctor -

I have not managed to keep his heel and foot down in the orthosis
........
 =================================================================================

here are soom of the responses we gut:

1)
Take a cast for an AFO, and pull an SMAFO (supermalleolar AFO,which will
allow plantarflexion, and comes over the dorsum as
much as possible, given the seam will be there) and put on a velcro
strap on the dorsum of it. Then pull an AFO directly over the SMAFO,
and make it an ankle strap at 45 degrees. Trim it to (or maybe just in
front of) the malleoli, so the SMAFO
can be pulled out, but it will snap into position when donned.

The SMAFO is easy to get on right, as the kid can be plantarflexed if he
insists. And when you don the AFO, the SMAFO pops into place nicely.
The parents are sure it is on properly, the 45 degree strap holds the
SMAFO securely, and the SMAFO holds the
entire dorsum of the foot more securely than any strap could ever hope
to. Mold a tongue of 1/8 Pelite over the cast, and slip it under the
edges of the dorsum trim of the SMAFO. This will assure that the edges
of the SMAFO and/or the strap will not cut
in too much.

2)
The only choice left may be the R Wrap design that is attributed to
John Russell. It is two shells of 1/16 ploypro which are near full
circumferential. Actually much simpler to get on then one might imagine
and very effective in calming the tone. Research his writings or
Beverly Cusick

3)
Typically these problems are found in kids with spasticiy and limited
range of motion. If serial casts were not used you might consider
setting the ankle at 90 degrees before progressing to 5 degrees of
dorsiflexion. Other things to consider...1) Physical therapy should be
consulted to institute a stretching program 2) use a thin ethylene shell
with velcro to spread the pressure over the dorsum of the ankle (donning
is made easier if the childs hip and knee are flexed, high chairs work
great) 3) high top lace up tennis shoes 4) flare the area just proximal
to the calcaneus to
help reduce the redness, your control is from the calf and footplate not
the heel cup in this young of a child.

4)
On small children with club foot, and chubby legs I add a transverse
bump on the inside of the shell just above the calcaneus, ie on the
archilies tendon. This hooks over the calc, and in concert with the
strap on the front holds the foot down.

5)
First, in my experience, you have to meet this child's tissues at least
half way. Here are my suggestions if you're interested:

If I were managing this child's case, I'd start either with a serial
casting course - a well-known, established and effective way to treat
young hypoextensible tissues with low-load, prolonged elongation
combined with weightbearing to the heel. I would align the ankle at a
few degrees past the first catch DF range of motion (with knee flexed)
in each cast, and hoep to be done gaining adequate range of motion in
about 4 casts. Then I'd go into a maintenance program featuring 2 to 3
hours per day wearing a
bivalved, DF'd AFO - set in about 15 degrees DF - during daytime active
hours. Close monitoring of ROM - as in monthly for 6 months, shouel tell
you whether daily maintenance or 4 days/week or some other schedule is
needed.

If casting is not going to happen, then at least set the ankle in an
articulated AFO at about 5 degrees past first catch end range (even if
that means setting it in 10 degrees plantarflexion), apply a skid-resist
surface layer to the fully-contoured floor, and post the heel with a
wedge to assure that it receives an appropriate pounding at initial
contact with each step. As range improves, erduce the height of the heel
wedge.

You can make the foot section tall enough in the back to apply calcaneal
capture adding posterior to the malleoli and anterior to the heel cord
(in that little sulcus), to keep the heel from sliding up, presuming you
have an intimate capture on the calcaneus in other respects.

You might also apply elasticized DF assist velcro straps for about 30
minutes every day, to give the tissues soem passive elongation during
say a meal ro snack time. Not at night, however - this usualy fails.

To hold the foot, use the now-standard dorsal wings and instep strap to
package the midfoot and distribute contact pressure over the greatest
available surface area. Or try a thin dorsal ecto-skeletal-like plastic
shell - like an R-wrap orthosis - before donning the AFO.

Beverly Cusick, MS, PT

6)
What I have used in the past is a 3/16 inch thick, aliplast pad placed
just proximal to the apex of the calcaneous. This is used in concert
with a figure 8 strap. Also you need to insure that your trim lines at
the maleolus are posterior enough that the figure 8 strap does not
bridge.Sometimes just adjusting the trimlines more posteriorly so the
figure 8strap is more effective , has been sufficient. I have used
the same pad when infants have been able to get out of straight last
shoes that have the
strap across the instep. One last tip, you may try attaching the figure
8 strap inside the AFO rather than on the outside.

7)
You may wish to try a full wrap-Inhibitive type of AFO.

Briefly; set the ankle to 90 degrees, modify well the
longitudinal,metatarsal and lateral arches. Pad malleolus with 1/8 med
density pelite, pull plastic . Leave seam (anterior)very close from
proximal edge to met heads then extend under sulcus to
full length of toes (may wish to extend your cast 1/2 to allow for
this).

Fit on patient; mark the sulcus (2-5 toes) and extend them with 3/16
medium to firm density material (Pelite) leave the first ray neutral. I
strap @ instep (1) and proximally (1 1.2).

8)
I have had good success with holding tight heels with a material called
erkoflex which is a bioflex rubbery silicone material. It is heat
moldable and makes excellent straps, valgus/varus controll straps,... It
allows a bit of stretch (almost like a strong elastic band) which holds
the dorsal section of the foot quite well. I buy it from Orthoactive in
B.C. Canada (www.orthoactive.com) or 1-800-663-1254.

9)
This may help. Try making your AFO out of TPE and then making a clam
shell for
the anterior part. Because it appears he does not have any ML
instability this
should work. After the tendon stretches out you can keep the anterior
portion
off.

10)
In this type of situation I always try to keep the side walls of the AFO
short
so that the straps can keep a good purchase on the limb, occasionally I
glue
in small pads just above the calcaneus and below the ankle to try to
keep
things snug. If the problem continues, I fabricate a 1/16 inch
polyethylene
instep piece that slips into the posterior shell and snug it up with a
figure
8 strap.