TIP OF THE MONTH: December 2013/January 2014
by Beth Meyers, OTC
One of my favorite dilemmas in Orthopsedics is being presented with a need (obstacle) and coming up with a safe, comfortable, functional solution to satisfy the physician and the patient.
My skills offer the team an important piece of the treatment effort. As an OTC, our role offers opportunities to implement creative solutions to improve the treatment of our patients.
Need: Casting a patient in the Equinus position with the intention of weight bearing.
Goal: A functional cast that is comfortable, lightweight, sturdy, and safe to assist in treatment goals.
Outcome: Happy patient, happy physician.
Equinus weight-bearing cast.
As non-surgical versus surgical treatment for Achilles rupture is being debated, my technical skills need to make adjustments. After some trial and error, this was my solution for patients who are being treated non-operatively for Achilles tendon ruptures, partial tears, and patients who progressed to weight bearing status after Achilles tendon repairs. This technique can also be utilized for serial casting situations for contractures seen in C.P., TBI, or patients who need to be maintained in Equinus and eventually progressed to neutral while being allowed to bear weight. I have placed a number of very active plus-size patients in this cast with no problems, and they were actually quite happy.
To begin I apply a short leg “base” cast with toe plate in the normal fashion. The patient is seated on the exam table with the foot in a relaxed plantar flexion position. I make sure that I make the “base” cast with minimal fiberglass, as you will add fiberglass at each step. I also add some extra padding under the metatarsal heads, as the patient’s weight tends to be loaded in this area.
Left: Base cast. Right: Toe Plate
I take care in molding, paying special attention to mold over the Achilles tendon, posterior calcaneus, and posterior to the medial and lateral malleoli. I extend the toes on the plate while molding for more comfortable positioning during weight bearing (as in a high heel shoe).
Next, I will have the patient weight bear with both feet on the floor to build the wedge heel. Have the patient face the exam table for balance (a walker would get in your way). I ask the patient to position their affected cassted foot in a position of comfort. As they are now protected in the base cast, they can take a few steps (with an assisting device to remain safe) in order to observe their position of comfort during gait.
I will now have the patient stand at rest while I fan fold 3” fiberglass in six to eight layers to fit from the metatarsal heads to the gastroc, making sure the fan folded slab is long enough to fashion the plantar surface of the posterior wedge flat on the floor. Once you are satisfied with the length of your fan-folded slab, you can secure the distal and proximal end of the fan-folded slab with more fiberglass around your base cast.
At this point with the patient standing still, you can mold the plantar portion of the wedge flat to the ground.
Left: Mold and hold. Right: Posterior, planter support.
Once the fiberglass has hardended, and you are satisfied with the position, you may ask the patient to take a few steps (again with an assisting device for safety) to check ease of weight bearing before completing the cast.
I tell students that with any casting situation “NO cast egos allowed” If it is not right in your mind or in the patient’s mind, IT IS NOT RIGHT. You must make adjustments. NO EXCUSES!
The patient may now relax on exam table.
Fan fold another 3” fiberglass slab of six to eight layers and apply medial, lateral over the posterior wedge, up to distal tib/fib, and over-wrap the whole cast, including the toe plate.
Top Left: Six to eight fan folds. Top Right: Over-wrap cast. Bottom Left and Right: Finished casting.
It is difficult to fit a cast boot over this cast. Here are some solutions: 1. Tub appliqués to bottom of cast (patient can wear a pillow case or stockinet over cast at bed time to keep sheets clean). 2. You could also add Velcro extensions to straps of a Gerry rigged cast boot.
When decreasing the plantar flexion with serial casts, plan extra time for stretching or a PT visit (If available in your clinic) between cast changes. You may utilize a cast stand for these cast changes, or you can place the patient prone, with their knee in 90 degrees on the table, and start with a posterior fiberglass slab to position the ankle with more ease and complete the base cast after the posterior slab hardens. Or, use a second set of hands if you are so fortunate.
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About the Author
Beth Meyers CST/SFAC, OTC
I have worked in the Twin Cities in Orthopaedics for 23 years in private practices, one-on-one with orthopedic surgeons, and in hospital settings.
I first assist in surgery and handle all clinical duties. I am experienced in everything from pediatrics to trauma. I have taught casting and splinting to physicians, PAs, PTs, MAs, nurses, techs, etc. around the country and locally for two different organizations and independently. I trained with Dr. Ponseti and assisted in implementing his technique in the Twin Cities. He is my hero! I have applied casts on patients age newborn to 101.
I am currently working at HCMC (Hennepin County Medical Center), a level-one trauma center and public teaching hospital in downtown Minneapolis.