Arthrogryposis Responses, part2
Troy Fink, C.O.
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Title:
Arthrogryposis Responses, part2
Creator:
Troy Fink, C.O.
Text:
9)
I do mainly pediatric orthotics. As far as taking a mold, I would do it. I
use metal finger splints as barriers for cutting off the mold with a knife.
If you have the skill to use low temp on this infant a cast will not be that
difficult. Just do not make the <<this is all the was to this reply>>
10)
I have done the following for twenty years or so. Use a single mold to
fabricate both the EO and the WHFO. Fabricate the WHFO first and apply it to
the mold apply a stockinet, a nylon, a PVA and another nylon (prevents
stockinet sticking to polypro or polyethylene) over the WHFO and the rest of
the mold. Fabricate the EO. Maintain a 2 to 3 over lap (EO over WHFO)
when trimmed. The 2 should work independently or as a unit.
Good luck
11)
Ok, I think that custom fab from a positve model certainly makes for a
better product, but considering the more rapid growth potential of an
infant, low temp plastics approach will probably be more cost effective to
the payor source. Given the fact that any joints you might have as options
for ROM may not be small enough either, this too supports your current
approach.
As for the conflict in fitting the two sections having opening trimlines in
differing planes, assuming I'm visualising this correctly, could you not
apply the WHFO first and then the EO overlapping it much the same as PVC
(plumming) joints overlap each other?
12)
Hey Troy!!!
.....
As far as your little girl.... how about just doing a two piece overlap EO
/ WHFO....
Use your low temp plastic - form the elbow, keep it on, then form the WHFO
section - overlapping the EO - then velco them together for the night time
use. Of course the custom to cast is always so nice - but gets expensive
with a growing child. You can take a lot of measurements of her....cast your
son...and carve away to get to the measurements.
Well - see what other ideas come in .. Take care...
13)
A suggestion for the design of the child's Ox. If the orthosis is to be
static, you may be able to accomplish your control by joining the WHO to a
biceps type cuff with a steel corset stay. The corset stay is easy to work
with and can be replaced as needed. Most O/P offices have these. If you
are looking for a more dynamic approach you may want to try B/E joints used
in upper Extremity prosthetics. These are in different sizes and are
available in single axis, polycentric and step-up hinge types. You may also
want to try Nyloplex. This plastic was/is used for upper limb orthotic
fabrication with wrist driven systems and static systems. Nyloplex can be
twisted and changed by heating it, while it is off the Patient.
Certainly, a mold of the child would help. If the child can be given a
kiddie cocktail, etc you can take an impression using plaster splints
3-layers thick and do a bivalve type impression. Otherwise look for a near
life size doll that you can make an impression of the arm. There may be
other options for fabrication. Let me know if you may need them.
Good luck,
14)
Give them the name of a competent OTR. OTR's can bill for hours of time
spent, you can't and this project is so labor intensive it's doubtfull you
can continue to follow this child affordably.
The OTR could afford to spend the time and experimental efforts in treating
this child.
I've been involved with these children over the years and eventually the
requirements exceed your available efforts.
If you have the competent OT available they would love the challenge and the
referral, it's the best of both worlds for you.
Hope this helps,
15)
This is exactly right for a young lady with AMC. Clubfoot srugery usually
works out very well, and the UE splinting will not correct all deformity
but should provent progression and maximize fucntion. Sometimes you will
get surprising improvements, given that the underlying muscle imablance
does not go away! Often our therapists do at least the early splinting
with low temperature materials and exact fit and quality (in terms of
durability) is not so critical, you expect them to outgrow rapidly and
also need adjustements as ROM increases.
For the specific design question, I'd wonder about sort of a spiral wrap
design such as has been used for an old style of TRAFO in the past (we
never use it and I forgot the name!) Another option would be a bivalved
cast...again, not durable but not too expensive to do and redo as needed.
Working with our kids with AMC is usually lots of fun and very rewarding-
they are usually very bright and figure out ways to do things despite
their malpositions. One of the challenges is to make sure any surgery
that is proposed (other than the obvious clubfoot correcetions) is not
going to decrease fucntion in any way; for example, knees in extension
should generally be left that way, and it MAY be OK to create one flexing
elbow with a tendon transfer but I have rarely seen anything else helpful
in the upper extremtity. I think the Avenues newsletter and site is still
in business, and of course arthrogryposis is one of the easiest things to
look up on the web as long as you can remember how to spell it.
ORIGINAL POST:
I have a patient, a 6 month old girl with a diagnosis of arthrogryposis. I
have been treating her for the past 4 months. I have provided KOs, EOs and
WHFOs for her. Her mother and PT have been very aggressive with stretching. I
have re-fabricated and adjusted the systems several times to accommodate for
growth and increased ROM. I have been using low-temp plastic and molding
directly to the patient. This has been working reasonably well, but it has
its limitations. Also, we (mother, PT, MD & myself) have elected not to
treat the ankles orthotically -- as she has an extreme equiinovarus deformity
bilaterally. The MD states that ankle correction is the first surgery he will
perform.
It is now time to replace the EO and WHFO. The mother states the pt.
tolerates both systems throughout the night. Unfortunately, she cannot wear
them both (EO & WHFO) at the same time, as they both cover the lower arm.
My goal is to provide EWHFOs. Part of the challenge is the trim lines. The
WHFO section should cover the Palmer region to provide extension forces at
the wrist and MCP joints. But with the wrist at neutral in the transverse
plane, as the trimlines approach the elbow, the plastic will cover the medial
portion of the lower arm. The trimlines are at the center of the anterior and
posterior aspects of the lower arm. Now, if I haven't lost you, you will see
the challenge arises as I integrate this into the elbow portion. At the elbow
I need to prevent extension, so the plastic should be either anterior or
posterior with the trimlines medial and lateral. Perhaps it could be more
simply stated: the WHFO portion is rotated ninety degrees relative to the EO
portion.
Any suggestions on how to accomplish this while maintaining maximal lever
arms and still practical and possible to don?
The other part of the challenge is I believe I could provide a better
orthosis if I could mold to a positive model. Any tips for casting an infant?
she is tiny!
Thanks for taking the time to read this. Any and all replies would be greatly
appreciated. In fact, any comment regarding pediatric arthrogryposis would be
great.
Sincerely,
Troy Fink, C.O.
email: <Email Address Redacted>
I do mainly pediatric orthotics. As far as taking a mold, I would do it. I
use metal finger splints as barriers for cutting off the mold with a knife.
If you have the skill to use low temp on this infant a cast will not be that
difficult. Just do not make the <<this is all the was to this reply>>
10)
I have done the following for twenty years or so. Use a single mold to
fabricate both the EO and the WHFO. Fabricate the WHFO first and apply it to
the mold apply a stockinet, a nylon, a PVA and another nylon (prevents
stockinet sticking to polypro or polyethylene) over the WHFO and the rest of
the mold. Fabricate the EO. Maintain a 2 to 3 over lap (EO over WHFO)
when trimmed. The 2 should work independently or as a unit.
Good luck
11)
Ok, I think that custom fab from a positve model certainly makes for a
better product, but considering the more rapid growth potential of an
infant, low temp plastics approach will probably be more cost effective to
the payor source. Given the fact that any joints you might have as options
for ROM may not be small enough either, this too supports your current
approach.
As for the conflict in fitting the two sections having opening trimlines in
differing planes, assuming I'm visualising this correctly, could you not
apply the WHFO first and then the EO overlapping it much the same as PVC
(plumming) joints overlap each other?
12)
Hey Troy!!!
.....
As far as your little girl.... how about just doing a two piece overlap EO
/ WHFO....
Use your low temp plastic - form the elbow, keep it on, then form the WHFO
section - overlapping the EO - then velco them together for the night time
use. Of course the custom to cast is always so nice - but gets expensive
with a growing child. You can take a lot of measurements of her....cast your
son...and carve away to get to the measurements.
Well - see what other ideas come in .. Take care...
13)
A suggestion for the design of the child's Ox. If the orthosis is to be
static, you may be able to accomplish your control by joining the WHO to a
biceps type cuff with a steel corset stay. The corset stay is easy to work
with and can be replaced as needed. Most O/P offices have these. If you
are looking for a more dynamic approach you may want to try B/E joints used
in upper Extremity prosthetics. These are in different sizes and are
available in single axis, polycentric and step-up hinge types. You may also
want to try Nyloplex. This plastic was/is used for upper limb orthotic
fabrication with wrist driven systems and static systems. Nyloplex can be
twisted and changed by heating it, while it is off the Patient.
Certainly, a mold of the child would help. If the child can be given a
kiddie cocktail, etc you can take an impression using plaster splints
3-layers thick and do a bivalve type impression. Otherwise look for a near
life size doll that you can make an impression of the arm. There may be
other options for fabrication. Let me know if you may need them.
Good luck,
14)
Give them the name of a competent OTR. OTR's can bill for hours of time
spent, you can't and this project is so labor intensive it's doubtfull you
can continue to follow this child affordably.
The OTR could afford to spend the time and experimental efforts in treating
this child.
I've been involved with these children over the years and eventually the
requirements exceed your available efforts.
If you have the competent OT available they would love the challenge and the
referral, it's the best of both worlds for you.
Hope this helps,
15)
This is exactly right for a young lady with AMC. Clubfoot srugery usually
works out very well, and the UE splinting will not correct all deformity
but should provent progression and maximize fucntion. Sometimes you will
get surprising improvements, given that the underlying muscle imablance
does not go away! Often our therapists do at least the early splinting
with low temperature materials and exact fit and quality (in terms of
durability) is not so critical, you expect them to outgrow rapidly and
also need adjustements as ROM increases.
For the specific design question, I'd wonder about sort of a spiral wrap
design such as has been used for an old style of TRAFO in the past (we
never use it and I forgot the name!) Another option would be a bivalved
cast...again, not durable but not too expensive to do and redo as needed.
Working with our kids with AMC is usually lots of fun and very rewarding-
they are usually very bright and figure out ways to do things despite
their malpositions. One of the challenges is to make sure any surgery
that is proposed (other than the obvious clubfoot correcetions) is not
going to decrease fucntion in any way; for example, knees in extension
should generally be left that way, and it MAY be OK to create one flexing
elbow with a tendon transfer but I have rarely seen anything else helpful
in the upper extremtity. I think the Avenues newsletter and site is still
in business, and of course arthrogryposis is one of the easiest things to
look up on the web as long as you can remember how to spell it.
ORIGINAL POST:
I have a patient, a 6 month old girl with a diagnosis of arthrogryposis. I
have been treating her for the past 4 months. I have provided KOs, EOs and
WHFOs for her. Her mother and PT have been very aggressive with stretching. I
have re-fabricated and adjusted the systems several times to accommodate for
growth and increased ROM. I have been using low-temp plastic and molding
directly to the patient. This has been working reasonably well, but it has
its limitations. Also, we (mother, PT, MD & myself) have elected not to
treat the ankles orthotically -- as she has an extreme equiinovarus deformity
bilaterally. The MD states that ankle correction is the first surgery he will
perform.
It is now time to replace the EO and WHFO. The mother states the pt.
tolerates both systems throughout the night. Unfortunately, she cannot wear
them both (EO & WHFO) at the same time, as they both cover the lower arm.
My goal is to provide EWHFOs. Part of the challenge is the trim lines. The
WHFO section should cover the Palmer region to provide extension forces at
the wrist and MCP joints. But with the wrist at neutral in the transverse
plane, as the trimlines approach the elbow, the plastic will cover the medial
portion of the lower arm. The trimlines are at the center of the anterior and
posterior aspects of the lower arm. Now, if I haven't lost you, you will see
the challenge arises as I integrate this into the elbow portion. At the elbow
I need to prevent extension, so the plastic should be either anterior or
posterior with the trimlines medial and lateral. Perhaps it could be more
simply stated: the WHFO portion is rotated ninety degrees relative to the EO
portion.
Any suggestions on how to accomplish this while maintaining maximal lever
arms and still practical and possible to don?
The other part of the challenge is I believe I could provide a better
orthosis if I could mold to a positive model. Any tips for casting an infant?
she is tiny!
Thanks for taking the time to read this. Any and all replies would be greatly
appreciated. In fact, any comment regarding pediatric arthrogryposis would be
great.
Sincerely,
Troy Fink, C.O.
email: <Email Address Redacted>
Citation
Troy Fink, C.O., “Arthrogryposis Responses, part2,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 6, 2024, https://library.drfop.org/items/show/214181.
