Summary: Transtibial casting techniques, Part 2

Summary: Transtibial casting techniques, Part 2

Ben Lucas

7/17/2007

Here are the rest of the summaries for transtibial casting techniques.

Thanks,

Ben

My casting techniques for transtibial patients varies dependent on the shape
of the residual limb and socket design. If casting over a roll-on gel
liner, I utilize a roll of elastic applied with tension and then reinforce
with rigid. I then reduce the model to the manufacturer's tension values
and evaluate the fit in the test socket. If I am casting for a conventional
total surface bearing socket, I utilize elastic and rigid wrap. I flex the
knee to 30 degrees, then wrap the residuum with elastic plaster reinforced
with rigid plaster. I wrap 1 inch proximal to the medial femoral
condyle. (Your tech will appreciate the extra height) While wet, I mold the
cast over the metaphyseal flare of the tibial and over the condyles. For
mature bony residual limbs, I utilize a 4-5 layer splint of rigid wrap to
lay over the anterior aspect of the limb. The splint starts at the distal
aspect of the patella and stops just distal to the cut end of the tibia . I
mold this into the contours of the anterior tibia and pretibs. Wait for the
split to harden then proceed with a circumferential wrap of flexible and
rigid plaster.
For PTS-SC socket, wrap residuum below the patella as described above.
Allow this mold to dry, then flex the knee to 45-50 degrees. Apply a 6
inch rigid plaster splint 6-8 layers thick and long enough to extend past
the femoral condyles. I mold the splint into the contour of the adductor
tubercle and hold the splint until it is dry. I index the splint to the
circumferential wrap and separate. The splint is rigid and does not distort
when removed from the limb. I cast the residual limb in 45-50 degrees to
expose the articular surface of the femoral condlyes when flexed. This
prevents necessary socket modifications during test socket evaluation

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Check the hydrostatic casting, Sandcasting, and the latest one by Dr Wu .

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Plaster is the only way to fly, I use one roll of 4x4 elastic and 1/2 to
one full roll of 4x4 rigid -extra fast. I do not preload anything; I just
smooth the plaster very well. For preparatory-temporary sockets I cast
over 2 thin cast socks with 1/8 thick, tibial and fib head pads sandwiched
between to provide ready-made relief. For definitive sockets using cushion
liners I just use one thin cast sock over the liner. Definitives using
locking liners, one thin cast sock and just a slight distal distraction
(more if the limb is bony, less or no distraction if there's redundant
tissue distally).

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For years I casted circumfrencially with flexible plaster then one wrap of
regular fast setting plaster, using my hands to shape and highlight where I
wanted. Recently we have started using Delta Lite Conformable fiberglass
wrap for all castings including AK and BK and especially AFOs. I usually
use the 5 inch for most everything. One roll for an AFO and it forms around
the heel and ankle just fine. No mess. For BK, I use one roll of 5 inch
and sometimes cut a 6 inch piece off to lay over the distal end first then
wrap distally to proximally. I then cover it with a thin wrap of Saran wrap
to hold the ends and snug the distal portion. Then again, I use my hands to
shape where I want. On AKs, we usually cast the patient laying on the sound
side. Two of us wrap, one wrapping and the other holding the cast up high
on the lateral and anterior trim. The other wraps then uses his hands to
hold the IT, medial and anterior shape. That works well for us and we use 2
rolls of 5 inch for an AK (usually).

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I cast everything under vacuum, using the 3-stage technique described by
Otto Bock and Carl Caspers. I fit 90% of my patients with Harmony or EVAC
VASS style socket systems. I use urethane liners, cushion style, without
cover exclusively. I use only rigid plaster 4 and 6.

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First a cotton cast sock is donned wet over a Seran wrapped residual limb,
and suspended with Yates clamps and 1 elastic webbing. Cast a TTA like you
would ace wrap a TTA, but first stabilize your sock markings with a
circumferential low tension wrap at the patella tendon level. Elastic 4
bandage is ideal first but not essential. The cast integrity comes from a
layer of 4 Selona fast set or similar. It's similarly wrapped, but with
tucks to ease the corners of the figure-8 wrap pattern. Without an elastic
layer, two rolls of fast set are often required if there is a large limb. I
like the two and three stage casting techniques for select limbs, but rarely
find it essential.

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For me it depends. With the congenitial with a distal end more symes like, I
do an anterior pannel and soup ladel it to incorporate the distal end. I let
it set up, then along the lateral boarder, i will soap and place a tube(any
cutting strip would work). Then wrap cuircumfrentially, I'll use elastic if
they are old enough to be cooperative, if time is an issue, then itts
straight plastrwer wrap. Once set, I remove the tube and use bandage
scissors. This way you have a nice circumfrential cast because the cut is on
top of the shell. (Works well for PTB AFO's as well). Rotationplasties I'll
run the tube laterally along the thigh which is medially along the foot.
I'll try to have it stay on the dorsum of the foot. Elastic wrap, then
plaster over top. Hand mold weight bearing along medial arch. (I added that
one for they are pseudo-transtibial). For adults, I do a two stage,
regardless of liner or suspension. I will work the anterior pannel to shape
the socket and define my weight bearing areas. Elastic wrap, not tight, just
to maintain contours, plaster wrap over.