Ambulatory and Cast Devices

1
Ambulatory and Cast Devices
2
Types

• Total Contact Casts
• Ambulatory Boots
• Wheelchairs, Crutches, Walkers
• Rigid Orthoses / EVA devices
• Heel Cushions
• Footwear (customised)
• Padding

3
Total Contact Casts

• The Total Contact Cast has been the Gold
  Standard for treating non-infected neuropathic
  foot ulcerations.
• The cast is well moulded with minimal padding
  allowing total contact with the lower leg and
  foot.
• By moulding casting material to the foot and leg
  weight bearing forces are spread out along the
  entire surface of contact, thus substantially
  reducing vertical force per unit area.

4
Example
5
Indications for Use

• Non-infected neuropathic plantar foot lesions
• Post operative delayed primary closures of wounds
• Pre-ulcerative wounds
• Acute stages of Charcot neuropathy
• To reduce oedema to improve wound healing
• To reduce stress on granulating tissue
• Protect foot from trauma
• Non-compliant patients

6
Contra Indications

• Infection
• Severe arterial disease
• Inexperience of the clinician applying the cast
• Ulcer must be wider than is deep
• Non-compliance
• Claustrophobic/ anxiety problems
• Skin conditions that precludes its use
• Contact allergies
• Low ABI
• Ischaemia
• Osteomyelitis
• Atrophic skin
• Blindness
• Obesity
• Ataxia

7
Method of Use

• The application of the cast generally requires
  two experienced podiatrists and takes approx 2
  hours.
• Assess the patient for their suitability to
  undergo this treatment.
• Provide skin and nail care, and wound care if
  required.
• Patient to sign consent form.
• Apply stockinette, poron padding to bony
  prominences and several layers of orthopaedic
  padding.

8
Method of Use

• Apply 4-5 rolls of dynocast pro or suitable
  casting material. Pay careful attention to the
  position of the foot holding it at 90 degrees to
  the leg and mould the cast well around the foot
  and leg.
• Allow a short drying time and saw off the cast,
  cutting the locks to aid correct fit.
• Dress all the edges of the cast and apply the
  velcro to secure the 2 sides of the cast firmly
  around the leg and foot.
• Give the patient complete written information and
  make a follow up appt.

9
Frequency of dressing changes

• T.C.C. requires an initial recasting 2-3 days
  after first appt.
• From then on regular weekly visits for
  debridement and recasting over a period of
  approximately eight weeks.

10
Advice to Patient/Caregiver

• Report to clinician if cast feels loose fitting,
  rubbing or painful.
• The cast will need to be replaced every 7 days.
• Keep the cast dry.
• Emphasise regular weekly visits.
• If you develop a fever, chills, nausea, vomiting
  the cast must be removed to ensure no underlying
  infection is present.

11
Advice to Patient/Caregiver

• Pt. will need to wear the cast for an additional
  2 weeks after skin has healed to allow skin to
  return to normal thickness.
• Cease smoking
• Self examination of cast

12
Ambulatory Boots

• An effective way to off load pressure
• Redistributes pressure over the entire surface of
  the sole of the foot and thus in turn the wound
• Decreases stress on new granulating tissue and
  provides protection
• Ensures an apropulsive gait to eliminate forefoot
  pressure

13
Examples of types and manufacture
14
Indications

• All types of neuropathic ulcers
• Neuropathic ulcers under the 1st MPJ and hallux
• Ulcers under lesser metatarsal heads
• Mixed neuropathic/ischaemic ulcers

15
Contraindications

• Unsuitable for ulcerations wider than deeper
• Certain dorsal and digital ulcers which are
  inappropriate due to their location
• Patients with an ABI of 0.35 or less
• Patients with diabetes and an ABI of 0.45 or less

16
Method of use

• 1. Sockinette is applied to the lower third of
  the leg, extending 10cm beyond the toes. 
•  2. Mark the lesion. Apply felt padding to remove
  pressure from the wound site.
•  3. Using 7mm semi-compressed felt cut a slab to
  cover the sole of the foot so that it extends up
  both sides of the foot and the heel.
• Use additional 5mm felt for valgus fillers or
  wedges if required. Cut a window in the felt if
  required.
•  4. Wrap a strip of 5mm x 7-10cm wide felt or
  sponge rubber around the ankle for malleolar
  protection and secure with micropore.

17

•  5. Hold the felt slab securely in place with two
  rolls of 10cm Softban. Evenly distributed over
  the whole area. Mark the lesion if necessary.
•  6. Apply one roll of 2 inch fiberglass from the
  toes to the ankle. Apply the remaining 3 inch
  roll from the ankle to the toes.
• Be sure to rub the fiberglass well to get a
  smooth finish. REMEMBER TO ALWAYS WEAR GLOVES.
• 7. It is important to get the patient
  weightbearing in a normal stance position to
  facilitate ambulation - it is best to stand on a
  piece of foam or similar to prevent sticking to
  the floor. 
• 8. Once the cast is dry mark the lesion and
  cutting lines.

18

•  9. Using a plaster saw, bi-valve the cast on the
  dorsum and trim to the required height and
  length. Remove the bi-valve.
•  10. Cut the sockinette and turn the sockinette
  back over the ankle and toes and secure with 3
  inch extension plaster.
•  11. Remove cast from the foot and seal the cut
  ends of the padding using 3 inch Extension
  plaster.
•  12. Apply a rubber sponge strip along the dorsum
  of the foot andankle.
•  14. Apply a 3 layer slab of fiberglass on the
  sole of the foot to create a rockerbottom sole.
•  

19

• 15. Wrap another roll of fiberglass around the
  foot from the toes to the ankle.
•   16. Mark the bi-valve on the dorsum of the foot
  and cut with a cast saw.
•  17. Cover the edges of the cut fiberglass with
  extension plaster so there is no sharp corners
• Refit the boot to the foot and hold firmly in
  place. A tongue pad of felt helps to add comfort
  and firmness.
•  18. Use a Post-Op walking shoe at all times when
  weightbearing. The cast can be removed and
  replaced as necessary for dressing, bathing and
  sleeping etc. 

20
Advice to patients

• Refrain from vigorous activities
• May swim, bathe or shower when clinically
  indicated
• Should be cautious against accumulation of
  foreign materials under cast
• If cast gets wet, make sure it is dried
• Prolonged frequent wetting without drying may
  lead to macerated skin

21
Wheelchairs-Indications

• Complete off loading of a wound
• After major surgery
• Preventative measure for older patients eg)
  falling over and knocking wound.

22
Contraindications

• Stairs, buses, trains
• Hills
• Doorways
• Bulky and unaesthetic
• Need power in arms
• Expensive
• Pressure sores
• Getting in and out of chair may be difficult

23
Crutches

• Underarm Crutches

Forearm crutches
24
Indications

• Pressure under arms
• Need good balance
• Expensive
• Difficult to carry objects
• Easy to knock wound
• Easy to accidentally put weight on limb eg) due
  to weak muscles
• May cause cramps from holding in a certain
  position

• Offload pressure
• If complete non weight bearing is not indicated
• If a wheelchair is not indicated
• For unilateral offloading

• Contraindications

25
Walkers
26
Indications

• Wider base of gait, so improving balance,
  therefore less falls
• Preventing fall will protect wound from being
  knocked
• Gives patient support and a feeling of support
  when walking

• For non-weightbearing
• Stairs
• Bulky and unaesthetic

• Contraindications

27
Rigid Orthotics / EVA Devices

• Features
• Provides great functional and accommodative
  control to prevent abnormal pronation and support
  deformities
• The materials used prevent shape alteration and
  damage to the device
• Extend along the plantar surface of the foot to
  just beneath the metatarsal heads.

28
Manufacture of Rigid Orthotics

• Made of rigid thermosetting plastics,
  thermoplasics.
• Plaster of paris mold of the individual foot is
  made with further additions of plaster for
  further control over specific areas of the foot.
• Plastic is heated in oven until softened and is
  placed over the positive cast of the patients
  foot, and than vacuum molded.
• The mold is than cut to size and grounded to fit
  the positive cast.
• Orthotic covers vinyl or leather

29
Manufacture of EVA devices

• Various densities of EVA may be used, selection
  will be dependent upon patient needs and medical
  history
• EVA is heat moulded directly onto the
  weight-bearing foot
• Devices are grounded to shoe dimensions
• Additions such as a rocker, met dome or wedging
  may be incorporated when indicated

30
Indications

• To prevent ulcer formation or reoccurrence in
  diabetic sensory neuropathy of the feet. Soft
  padding, eg, low density EVA can be added to the
  rigid orthotic area, which has a pre existing
  wound or ulcer to redistribute pressure away from
  this region
• Abnormal pronation
• Limb length discrepancies
• Back, knee or foot pain
• Plantar fasciitis
• Neuromas
• Hypermobile pediatric pes planus
• Forefoot deformities
• Hallux abductovalgus secondary to pes planus.

31
Contra-indications

• Limited joint and muscle ranges (ankle joint
  equinus)
• Patients with rheumatological joint changes
• Fibromyalgia

32
Method of Use

• Patients should begin wearing orthotics for one
  hour and increase it by an hour each day until
  patient feels comfortable wearing them daily. A
  review period of 4 weeks is essential.
• Rigid orthotics lasts between 2-4 years.

33
Advice to patients

• Patients should make an appointment if any
  discomfort arises during use of orthotics
• Wear socks/stockings to reduce skin irritation
• Clean orthotics with warm (not hot) water and
  soap
• Place orthotics in frequently used footwear wide
  toe box, lace up, little or no heel, extra depth
  and fitting the foot correctly.

34
Padding

• Types
• Felt, foam, silicon
• A cost effective and simple way to offload
  pressure
• Easy to apply
• Provides extra cushioning
• e.g. Heel Pillow

35
Allevyn Heel

• Non-adhesive anatomically shaped dressing made by
  Smith and Nephew
• Used on moderate to highly exuding wounds
• Fits over the heel to promote soft, cushioning
  pressure relief and in turn promote wound heeling

36
Therapeutic Footwear

• Therapeutic footwear is an accommodative measure
  that is an important part of wound management.
• Features include
• Deep toe box
• Soft pliable uppers
• Firm heel counter
• Rigid shank

37
Wound care shoe

• Aimed at reducing amputation rates in patients
  with ulcers
• Multi-density insoles that can be cut as required
  to off-load areas of pressure
• Contains a semi-rigid rocker sole
• Soft EVA-lined leather
• upper
• Cost 159-Darco

38
Healing Shoe

• Aka Ortho wedge
• Used in treatment of diabetic ulcers
• Protects the forefoot by removing most pressure
  from met heads and digits during propulsion
• Also indicated as a post-operative shoe
• Costs around 30 from Darco manufacture

39
Summary

• Its not what you put on the wound its what you
  take off