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Metatarsus Adductus Serial Casting

Discussion in 'Pediatrics' started by Guito, Sep 19, 2010.

  1. Guito

    Guito Member


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    Hi You'll

    I was after some confirmation/advice regarding serial casting.

    I have an 8 month old patient who is just starting to weight bear and is self-removing current splints during the day.

    I am considering a unilateral serial cast as the deformity has improved but needs further correction.

    I have done casts on patients before, but the last was 5 years ago.

    Normally, the casting procedure I would do would be:

    1. Few minutes of stretching/holding in corrected position.
    2. Apply TBCo. or occlusive agent
    3. Apply stockinet and 2 layers of softban(undercast padding) with extra over pretibial and mall. areas
    4. Cut plaster bandages into 5cm wide rolls
    5 Apply plaster and hold in corrected position, sl inverted and with foot/leg at right angles
    6. I then would normally apply a roll of fibreglass around the foot/ankle to avoid cast breakdown.
    7. Review for cast change in 2/52


    Could I get advice on:

    1. I am allergic to TB Co. - any substitutes

    2. Some pods apply bandages to leg up to base of the 5th met initially then apply the foot section 2nd once the leg part has dried. Some pods will do the foot section 1st - any advice/tips appreciated.

    3. In past cases the cast removal is never fun, especially is fibreglass is removed. I haven't used a cast saw since uni, but I should be able to borrow an Orthopod's who works from the same centre. I have used plaster shears before but they re tricky on a small leg. - any advice appreciated.

    4. Use of normal or fast setting plaster?

    5. Any modern substitutes instead of adding fibreglass for easier removal? And if not using fibreglass, do you have success with parent's plaster removal the night before the cast change?


    6. Also is 2/52 between cast changes reasonable or would you go less on the 1st cast.

    Thanks for any input

    Guito
     
  2. vbpedorthist

    vbpedorthist Member

    Have you tried orthopedic shoes. Markell is still around and they have open toe boots the tarso pronator made specifically for metatarsus adductus. They have an internal buckle strap to secure the foot and then laces. They can be worn for 24 hours.
    If you have alot of patients this could be a good source for you. I use them from time to time in our practice. Check out there website www.markellshoe.com., see if this helps.

    Good luck
     
  3. Guito

    Guito Member

    Thanks for your reply.

    The plan was to correct the remaining adductus with a cast and followed up with corrective shoes. The deformity is still moderate ++ and I think it needs to be treated with more force than a corrective shoe. Also the pt is pulling off splints and shoes. I have been using Schein antivarus shoes for older kids (www.schein-shoe-service.de)that have worked well, but I'm not sure how small the shoe sizes start.

    Thanks for the link to Markell shoes. I'll look into them.

    G
     
  4. Bug

    Bug Well-Known Member

    After 5 years, I would caution against casting, as the poor outcome potential outways the good. The risk of casting baby foot without an acute/orthopaedic backup is a potential nightmare. Will you be answering your mobile at 4 am with a child screaming from a potential too tight cast?


    If the foot is flexible past the midline, I would leave it, research shows the majority of the flexible metatarsus will self correct.
    If the child isn't ball sleeping or sitting on the foot, I would leave it and let the body do it's thing while giving some footwear choice guidance.

    If it is flexible and severe or semiflexible, at this age, 12 hours of sleeping and car trips in a splint with still provide some corrective force up to the age of 2.


    If it is rigid, you need to send it off for a surgical opinion.
     
  5. Admin2

    Admin2 Administrator Staff Member

  6. Sally Smillie

    Sally Smillie Active Member

    Listen to Cylie. Don't touch it.

    Also, if will correct to rectus / mid-line casting isn't indicated anyway, at that age you can still stimulate peroneals externally, and let nature take it's course with the rest. 95% spontaneously correct without potentially munting up the foot with casting. The orthopod I work with wont cast unless it is rigid in a met adductus position and then I'd get his physios to do the casting, they do it every week and vastly better than myself.
     
  7. Guito

    Guito Member

    Cylie and Sally

    Thanks for your advice. My option to possibly serial cast was based on a phone conversation with the mother. She said the child was removing the current corrective aquaplast splints all the time, so I thought plaster might be an option if the deformity was severe enough.

    I reviewed the child the other day and I don't think the met adductus is severe enough to cast. It can be manually corrected past the midline.

    I have given the mother several pieces of stockinet(double length) to "enclose" the splints to discourage removal.

    I have some questions regarding Rx.

    1. Do you still use aquaplast type splints in cases that are flexible and correctable past the midline, before they commence walking, or as a night splint in an older child to encourage correction, even though you wouldn't serial cast?

    2. The remaining amount of met adductus is mild. During wt. bearing and assisted walking the child has a moderate-severe amount of hallux adduction. Can you recommend a Rx or splint modification to assist with this? I was thinking of adding a 2mm multiform hallux loop, with dorsal and plantar extensions(directed laterally) velcroed to the lateral aspect of the splint applying a mild abductory force.??

    3. Which ant-varus footwear have you had good results with at the 8-12 mth age group?

    I appreciate your advice.

    Cheers

    G
     
  8. Bug

    Bug Well-Known Member

    I make an aquaplast sleeping splint but only if the deformity is semi-flexible or flexible AND severe AND they are a ball sleeper. They are sleeping for 12 hours a day, that is 12 hours of corrective force. I will use them up to 2 years.

    When you think of a straight lasted shoe, it will apply the same force to a flexible deformity. If it is flexible and remains so then the shoe will apply this rather than a splint

    Nothing special, I teach my parents to look for a straight lasted shoe and go from there. There are some New Balance, some Clarkes. Then we talk about shoes for active play time, splints for sleep time and barefoot the rest of the time.

    The trick is making sure you are only treating what the body can't correct itself.
     
  9. Guito

    Guito Member

    Thanks Cylie, I appreciate your advice

    G
     
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