Re: Ischial Containment Casting Responses Part II

Re: Ischial Containment Casting Responses Part II

Robert Schiff

There certainly is much debate about what casting procedure is best
regarding Ischial Containment. As you may well know, variables to consider
when deciding how to best capture the AK amputee's Residual Limb and
skeletal structure include age of the patient and their tissue consistency,
whether male or female to determine anatomical differences of the pelvis and
pubic ramus/ishial tuberosity, length and maturity of the residual limb,
weather the suspension will include silicone liner and pin or suction as
well as patients activity level. Then the methods of obtaining a good mold
include freehand casting, measuring for CAD, casting with a brim, and
whatever other methods concocted over the years. I think all methods should
be in our arsenal of treatment approaches and all are very valid approaches.
Should those who prefer molds by measurement be criticized because they do
not hand cast? Not at all. If anything molds by measurement allow the
practitioner an opportunity to create a socket via methods different from
hand casting or brim casting. I have found that the newer, fleshy RL's are
able to be measured quite effectively and the choice of brim styles are
great to help with customizing the socket to the patient. I have found that
certain brim styles work better for geriatric patients than others. I have
also found that certain brim styles work better for female amputees than for
male patients. Other considerations for women that I have found to be useful
are whether or not the woman has given birth. This is information that I
believe is important to help determine if the pelvis could possibly be
altered as a result of natural child birth, creating pelvic obliquity or
tilt. I have found that some women have an anterior tilt which prevents
optimal ishcial containment. This also requires more space for the pubic
ramus when the pelvis is tilting anteriorly. The socket then begins to show
specific characteristics unique to women's anatomical structure.

As well, the older amputee who's muscle structure in the thigh/buttock area,
particularly near the insertion of the hamstrings, is less defined than in
younger amputees, and the skin tends to be more fragile. Contractures are
more likely in the older patient and the ability to stand for a hand molded
socket is certainly a factor.

With these few examples of the different variables to consider...choosing
the best style of casting becomes a real art. I have been taught and have
utilized a technique developed by Jan Hattingh utilizing IC in conjunction
with a silicone liner with pin. I coined his design as the delta socket in
that it has a triangular shaped brim when completed. I have also used a
method taught by Wayne Daly which involved the patient laying on his contra
lateral side with a partial medial brim used to define the musculature and
anatomy in the inguinal region of the RL. This method allowed for a
wonderful capture of the femur laterally for rotational control. Finally the
method that I have found to work well as far as hand casting goes is a
method taught to me by Gerald Stark. It is the method he and his compodrees
at Northwestern created. It is the most scientific approach to developing an
IC socket that I have come across so far. They have a specific format to
follow and it is the closest thing that I have seen to a formula since the
quad socket formula. It gives you a better way of quantifying your data from
one patient to the next. I found that the subichial triangle they
introduce is a key ingredient to IC capture that other methods have not
utilized or focused on.

I think that the IC socket is evolving as we speak and there is no one right
way to achieve a true IC socket. In fact the only true constant with the IC
socket is that you need to get Ischial containment. How you get it is
determined by more variables than a standard quad socket seat ever had to
consider.

So in short.....the answer to you question in my opinion is.....It depends.

Just my opinion

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Hi there..I use both hand casting and brims, what determines which one i use
is the patients residual limb.if they present with a normal shape and size
of limb i can usual fit a brim with no problems and that does speed up the
process and gives good consistant results usualy only 1 test socket is
required....I hand cast when the limb is of an odd shape our size,our if the
tuberosity is an odd shape. either way corect and proper dimensions are
extremely important..hand casting definatly takes experience to get a good
cast and not have to do 2 our 3 test sockets.also an extra pair of hands
during casting helps alot..when i use brims the patient is weight bearing in
the brim and i have made certain the tuberosity is contained properly...hope
this helps..

-----------------

Hey Robbie,

How's the real world treating you? Far different then UT I hope.

I still prefer hand casting with the exception of very large legs which I
will then do by the numbers and get a socket sent in. I am also averaging
about 2 test sockets. I could use fewer but I prefer to pull the test socket
then to do the definitive socket and have fitting problems. I also try to
give the pt. a chance to use the leg in their home environment before the
actual completion/definitive fitting.

I have not used many IC brims other than for Post Op applications. My
intuition says that some brims will fit some limbs well and the others will
have to be adjusted. Why guess when I can do it by hand. I am a bit old
fashioned that way.

Good topic. Glad to here you are in it up to your elbows.
----------------
Hi Robbie,
I have moved from casting with straps to measuring/faxing when I became the
sole practitioner/technician etc. I can measure and have a T/S here
tomorrow that will be an excellent starting point. Isn't that all that most
of your first Test Sockets are anyway? (I usually get it done in two).

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