Casting for Clubfoot

Original Editor - Africa Clubfoot Training Team as part of ICRC and GCI Clubfoot Content Development Project

Top Contributors - Naomi O'Reilly, Chelsea Mclene, Kim Jackson, Simisola Ajeyalemi, Rucha Gadgil, Meaghan Rieke and Olajumoke Ogunleye  

Introduction

The application of casts is a crucial part of the correction of clubfoot deformity. The cast is needed to maintain the correction that has been achieved by manipulation. If the cast is badly put on it can slip and lose correction, it can also cause rubbing and skin breakdown. Like all skills, it is best learned by practical demonstration but this chapter outlines the key points.

What Do You Need?

• Pirani Scoring Sheet
• Pen
• Right Size Underwrap (usually 5cm wide)
• Right Size Plaster (usually 5cm wide in babies)
• Water
• Cover for Parents/Carers Clothes
• Foot Slab from 4 - 6 Layers of Plaster
• Knee Slab from 4 - 6 Layers of Plaster
• Scissors / Blade
• 2 Trained People:
  • 1 Trained Person to Manipulate
  • 1 Trained Person to Cast

Roles

Manipulator

Position:

The individual Manipulating the Foot Stands On the Lateral Side of the Foot

Role:

• Directs Treatment
• Measures the Pirani Score
• Manipulates the Foot
• Determines the Position of the next cast
• Moulds the Cast
• Remember: “Assess, Plan, and Treat”

Caster

Position:

The individual Casting Stands on the Medial Side of the Foot

Role:

• Records Pirani score
• Wraps the padding and casting material onto the leg
• Holds the knee whilst the manipulator moulds the cast

Parent/Carer

Position:

The parent carer present where possible should be Breastfeeding or Feeding Baby or Standing by Baby’s Head

Role:

• Comforts baby
• Keeps baby as still as possible
• May help to stabilize the thigh whilst the lower part of the cast is wrapped and moulded.

If the mother is sitting, the manipulator should stand on the mot right if it is a right foot, and the parent/carers left if it is a left foot. The caster stands on the other side. If the mother is going to breastfeed it is best if the child sucks on the breast that is the same side as the foot, i.e. left breast for left foot

Thus:

• Right Foot = Right Side for Breastfeed = Manipulator on Mother’s Right
• Left Foot = Left Side for Breastfeed = Manipulator on Mother’s Left

Remember: TWO People Required To Cast

Positions during Casting

What Makes a Good Cast

Communication

• Know who is manipulating and moulding
• What is your aim for this cast? Know what position you would like to achieve

Underwrap

• Each turn is overlapped by half, Creating 2 Layers
• Toes are covered and underwrap goes all the way up into the groin
• 3 layers at the groin to stop rubbing
• Wrap Snugly

Plastercast

• Correct and Continuous Manipulation
• Footplate to Tip of the Toes
• Complete Below-knee Cast First
• Moulding Above Heel to Prevent Slipping
• Knee at 90 Degrees
• Knee Plate in Bigger Infants
• Plaster Goes Right up the Back of Thigh
• Trim Back to See Toes

Casting Process

Manipulate the Foot

• Identify Lateral Head of Talus
• Manipulate the foot for around 60 seconds to stretch the tight ligaments
• Determine the desired position of the foot and communicate this to the caster

Hold Foot for Caster to do Below-knee Part of Cast

• Manipulator holds the foot by the toes using the tips of his or her thumb and index finger to prevent crowding. The manipulator’s other hand can hold the baby’s thigh as the below-knee part of the cast will be done first
• Manipulator keeps their fingers inside the cast, applies cast over the fingers and completely over the toes
• Caster Wraps Padding: 3 turns over the toes, overlap each layer by half. The padding can extend up to the top of the thigh
• Caster wets the cast and wraps 3 layers snugly over foot and ankle but slightly looser over the calf to prevent unnecessary pressure on the muscles
• Complete the below-knee part of the cast first
  

  Casting Process Below Knee

Mould the Cast

Manipulator moulds the plaster gently around the foot and above the heel, keeping thumb over LHT moving so as to keep the correction but not to cause an indent. Keep moulding until cast has set.

Remember: Never Touch the Heel

Complete and Trim Cast

• Cast is extended above the knee high into the groin and the knee set at 90 degrees flexion.
• The manipulator can help the caster now by holding the dried below-knee part of the cast
• The groin end of the plaster should not stray over the edge of the padding or there will be a sharp edge of plaster irritating the skin
• A footplate can be added if the plaster is weak. This is simply a flat slab of plaster about 4 - 6 layers thick that is the size of the sole of the foot and supports the sole
• A knee slab of 4 - 6 layers can also be added to the front of the cast from lower shin to upper thigh if it appears weak
• Trim the cast back over the toes
• Discuss cast care with the parents

Remember: Toe to Groin Casts

Removal of Casts

Babies who are in the corrective phase of treatment will need cast removal every time they attend the clinic.

• The cast is soaked in water and then the bandage can be unwound
• This should be done at the clinic rather than at home as correction can be lost
• Removal of the cast using a plaster saw is noisy and can make the baby cry
• Some casters make the removal process easier by scrunching up the last inch of each roll of plaster into a ball so that it can easily be found

Resources

Casting Technique

The Ponseti method consists of a specific technique of manipulation of the clubfoot deformity, followed by the application of a plaster cast with the foot in the corrected position. A percutaneous tenotomy of the Achilles tendon is done prior to the final cast to gain complete correction in most patients. Bracing with a foot abduction orthosis is necessary to minimize relapse of the deformity. This video provides a demonstration of doctors casting a baby with club feet using the Ponseti Method.

Dr. Norgrove Penny, a "Christian Blind Mission" doctor and adviser talks some about his experience in the mission, mainly Uganda.

Advanced Casting Technique

There are advanced casting techniques in which the procedure shows one-handed hold to use when manipulating and casting the foot. For beginners, it is recommended to use the two-handed hold. 'The Ponseti Method of Manipulation', but as your technique develops you may wish to use a one handed hold as an alternative.