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CME Podopediatrics

Serial Casting in the 21st Century-PT1

Laurence Lowy, DPM

Laurence Lowy, DPM discusses the various aspects of serial casting of the infant.

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Goals and Objectives
  1. Describe the indications and contraindications of serial casting.
  2. Understand the rationale for treatment.
  3. Relate the steps in casting specific deformities.
  4. Recognize the possible complications.
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  • CPME (Credits: 0.75)

    PRESENT eLearning Systems, LLC is approved by the Council on Podiatric Medical Education as a provider of continuing education in podiatric medicine.

    PRESENT eLearning Systems, LLC has approved this activity for a maximum of 0.75 continuing education contact hours.

    Release Date: 03/16/2018 Expiration Date: 12/31/2018

  • Author
  • Laurence Lowy, DPM

    Associate Professor
    Dept of Pediatrics
    NYCPM

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  • Lecture Transcript
  • Hi, this is Dr. Laurence Lowy, Professor of Pediatrics at the New York College of Podiatric Medicine. I am also the Dean of Student Services. The topic is Serial Casting in the 21st Century. Part I, we will be dealing with the general considerations and overview of Serial Casting and in Part II we will be talking about the application of Serial Casting in various pathologies that we encounter in pediatrics.

    It�s important to note that even though the title of this lecture is 21st Century Serial Casting, Serial Casting dates back as far as hypocrites, who described in his writing, �Serial Casting, clubfoot by manipulating the clubfoot into a better position and then bandage it with material that is very similar to modern day plaster.� This Serial Casting was brought through the ages and wound up in other disciplines such as physical therapy, where there was application, reapplication in material when a body part was damaged or in some way a native rehabilitation. Flash forward to the 30s and 40s and we have [Indiscernible] [00:01:10] Gordon and Browne being of Dennis Browne bar fame, who advocated forceful manipulation. What they would do is they put the child under general anesthesia and literally breakdown the foot and then apply plaster material. Unfortunately this led to all sorts of problems, not the least of which was arthritic joints in an early age for these children. In the 40s and 50s it was Hiram Kite and later Dr. James Ganley who was a podiatrist, who learned under Kite, who trained under Kite. And they advocated gradual gentle correction overtime, [Indiscernible] [00:01:50] also was an advocate of this as an orthopedist who dealt and deals with children.

    With talipes equinovarus, all three of them particularly Kite and Ganley recommended a stepwise manipulation which we will be covering in Part II. And then of recent note and it�s only because there has been more publicity, Ignacio Ponseti who actually was writing at the same time as Hiram Kite, recommended with talipes equinovarus one manipulation, and then in early Achilles tenotomy in order to affective and appropriate change within a short period of time. You look at Dr. Ponseti�s writings, they do back into the 50s and 60s, but he really only over the last 10 to 15 years became truly popular in the literature. If I have a credo when it comes to Serial Mobilization Casting it comes from James L Le Noir�s [Indiscernible] [00:02:54] congenital idiopathic talipes where he said, �Each day the foot remains deformed is a day of golden opportunity lost forever.� I think this typifies how important it is to do Serial Casting as early as possible when you really can affect appreciable change without sequelae.

    With respect to lower extremity and a Serial Casting, the indications that we will cover in Part II are talipes calcaneovalgus, that is the �up and out� calcaneovalgus, that is congenital flatfoot, metatarsus adductus, talipes equinovarus or clubfoot and internal tibial torsion which remain somewhat controversial, but I will explain how I believe it�s a very good tool to do Serial Casting in a young child with internal tibial torsion. Contraindications and this isn�t an all inclusive list, but the large ones that you want to be aware of. Any open lesions on the low extremity that you are going to be applying materials to, suddenly you don�t want to invite any sort of infection or irritation. And this can be open lesions that are preexisting or as a result of your prior Serial Casting.

    If the child has Developmental Dysplasia of the Hip, (DDH) or what�s always been known as a dislocated hip, you certainly don�t want to put a material on this that�s going to weight on that side without any intervention from the orthopedist. So as soon as I know if the diagnosis of Developmental Dysplasia of the Hip I will let the orthopedist do what they need to do or give me the go-ahead to do Serial Casting on that child. If the child is sick or in some way infirm, it�s probably not a good idea to serial cast them, they can be fussy enough sometimes with Serial Casting it can be a fussiness involved and you won�t know if they are fussy because of the cast or their actual illness, plus there seems to be somewhat of a cruelty in my opinion to put a cast on the child who is ailing.

    I have immunizations as a question mark, again for the same reasons illness sometimes should be considered contraindication. The child that�s been immunized its not uncommon that they can spike a fever that day or that evening that next day. And also they can be a little fussy and you as a practitioner won�t know if it�s because of your cast or their immunizations. I don�t think this is an absolute contraindication. Same for most children, babies are going to get their immunizations in the upper thigh. If you have to apply a long leg cast, you have to make sure that either you make that cast a little shorter or in some way make sure that it doesn�t overlay the side that needs to be immunized, making it more difficult for the pediatrician.

    Complications are always possible, the largest one is skin compromise, it happens to the best of us. And you just have to be mindful that you don�t want to cast over the skin compromise until its full healed. Their iatrogenic complications, you can induce worse problems then the actual pathology that you set out to take care of. In Part II, I will be talking about some of the pitfalls so that you can avoid dislocation Rocker-bottom fracture or Flat-top talus. These are all relatively rare but in a young practitioner who gets overly aggressive they can occur.

    Problems can occur with any treatment of modality and Serial Casting is no exception. The cast can interfere with bathing the child will not be able to be easily bath in a tub or bassinet. Diaper changing can be a challenge to the parents both trying to apply and take off the diaper. And also if you have a long leg cast keeping that cast clean. And then clothing can be a difficult to apply if it�s too tight. And the parents often have to get, go to the next size which they generally have from all the baby showers.

    Children wearing a cast especially bilateral will have a more difficult time getting around, but I would say that most children are pre-resilient and I have had children crawl and walk in both short and long leg cast, but it�s something to be mindful out and tell the parents before you are going to start Serial Casting. As with surgery good preparation is good for a good serial cast. You have to get your environment ready and that environment should be a warm room because the child is going to be unclothe, should be a large room to allow all the people who need to be there free motion and then it should be free from distractions in a busy practice, you want to make sure that you are not, you don�t have the phone ringing of the hook or somebody coming in and saying Mrs. Jones needs, you know something or other. So it really should be an area that is sequestered from the rest of your office.

    We have got to deal with the people who need to be part of the preparation and also the materials. The very first people that you should be preparing are the parents. When we are dealing with the casting itself we should be telling them the reason for the casting that is why we are going to put their child that they love and carry into these casts that are so heavy and manipulate them, where they might be uncomfortable in the manipulation. We should talk about the method from shifting us just as when you are doing surgery, you talk about what you are going to be doing in all the aspects of the pre-op and the post-op and the inter-op. And then the expectations, we don�t want to lower parent�s expectations but we want them to have realistic expectations. Child coming in with a significantly rigid and severe talipes equinovarus will have a less chance of being a perfect foot than one who is postural and not as severe.

    The length of treatment try to give a ballpark, you don�t want to be holding you to it, but the bottom-line is parents want to know how long is your child going to be in that cast? We should also discuss the parents involvement that is that they are going to need to be there holding the child in their lap, probably getting messy with some plaster. And then they are also involved in taking the cast off later on. And in particular with talipes equinovarus, but I think that it�s a good idea to say this for any of the pathologies except maybe for talipes calcaneovalgus that there is always a possibility of surgery, don�t wanted a parent upset with you, because you never mentioned it and you get the child corrected so far but they do need surgery for the next segment. If you set it ahead of time the parents won�t be happy but at least they will be prepared.

    You also have to psychologically prepare the parents, by that I mean the child�s reaction to the cast, not only are they going to cry when you manipulate them and get more fussy as time goes on as you cast them, but you are also going to have the child again possibly curtailed in their activities. You also have to prepare them that the family that is grandparents and siblings and everybody is going to react. The child is coming home in cast for the first time and it�s not as if they have been in a skiing accident. So you have to let the parents know that the family may end up having some difficulty early on, it�s really important for the parents to be the educators as to why that�s happening.

    And then finally the child should be prepared and that�s both the parent�s responsibility and yours. Have them bring a full bottle and not give it to the child until you start Serial Casting, using shiny objects or toys that they like. What I use in my practice for many years, if you have a door full of keys that you don�t know where they go to anymore, sterilize them, auto clay them, put it on a small key ring and give it to the child, they love the jangling, they love the metallic taste and it�s a great distracter.

    Another person you need to prepare is your assistant, somebody who will be with you at every casting. They have to get that room prepared with all the materials you don�t want to have them spending time, going, I will get another 2-inch roll from the closet, time is of the essence and everything needs to be prepared. They should be able to anticipate your movements, now some practitioners will have the assistant to the casting and the practitioner is the one who ends up holding the limb, but the bottom-line is the assistant should know your every move. Again, I keep making the analogy to surgery but it�s very similar, just like an OR tech should have that instrument ready for you, your assistant should know where your hands are going to be and what the next step is.

    And then the way I have always used an assistant is they are the ones who maintain the body parts while you are casting. That is holding the opposite limb from kicking you, holding the limb that you are working on in the right position so that you can get optimal results. And then finally the practitioner him or herself that is you, the practitioner should have a real thorough knowledge of the deformity of the pathology and the manipulations necessary to achieve optimal results without any of the sequelae that can occur. I would like to think that you will have a great working knowledge of dealing with the four pathologies that we will in Part II after seeing these two lectures, but quite honestly unless you have a practical experience you will not be well versed in the actual application and really should seek out a practitioner who does Serial Casting so that you can truly learn it.

    A practitioner should have enough time blocked off in their practice in a busy practice it�s not uncommon to have 5 to 10 minutes per patient encounter. Here, I usually block off about 45 minutes to an hour so that I had enough time to do everything I needed to do, and wasn�t involved in any other patient care or day-to-day workings out of the practice. You need to train your assistant, that assistant should be ready to go, day one just as you should with that first serial cast. And then finally it�s very easy as a practitioner to get a little jaded and not realize what the impact of Serial Casting could be on the parent. Remember the parents you know they want their children perfect, they have only seen them cry generally when they have gotten shot. And they are not going to be used to their child being manipulated for a period of time, having the cast applied and all of the sequelae that we talked about. So have that sensitivity that it�s a big deal to them even if it isn�t to you.

    There are no hard and fast rules when it comes to Serial Casting, Hiram Kite used to Serial Cast children for talipes equinovarus up to the age of 8 and 9, I am not advocating that at all, but you know these are some guidelines that most of us follow. Bottom-line as I said with the Le Noir�s quote �You want to do it as soon as possible.� And within the first year of life, you will have the greatest result. Why is that, obviously because soft tissue in bone are very malleable and you can affect a pretty appreciable change, plus also the child�s activity level is going to be minimal at that time. It�s always best before the age of ambulation, I have cast children into ambulation, but their problems with that, with the ambulation comes faster ossification and also breakdown of cast and you are going to get more of the complications then if the child is just crawling or a mobile.

    And then, most people would advocate, don�t cast if the problem is a mild problem that you can get away with just stretching or stretching and taping. So generally when it�s a moderate to severe problem, I am a little more aggressive than some practitioners, I believe that if you just put on a couple of serial cast, that child is good to go even if it�s a mild form, but I think general, when to cast for most people, when its moderate to severe.

    Manipulation is key, that�s where we get our true correction, it isn�t the cast material that corrects it�s the manipulation and the cast material hold. I have seen many failures from various really top medical institutions where the parents come to us feeling that there has been a slow progress or no progress and often when I start manipulating and I ask did they do this, the parents invariably will say no, they just put the cast material on.

    The child should be in a parent�s lap as far as I am concerned although many people including my mentor Dr. Ganley, I believe that child should be on the examining table by themselves, but I find that the parent can comfort the child and also excess another assistant able to hold them with another pair of hands.

    The manipulations as a general role should be about 5 to 10 minutes, I will see in �violation of that rule� when we discuss the Ponseti method. The force as I said earlier should not be a real strong force, remember you are much stronger hopefully than a one month old or a five month old child. So it should be a gentle but firm force, always to resistance the child may cry but you don�t want to hurt them. And then once you are done with the manipulation, if you are effective, you shake the limb and it�s going to hold in the corrective position for a short period of time. If you shake it and it goes right back immediately you got to manipulate a little longer.

    As I discuss some of the mechanics of what should be part of this Serial Casting, I am going to preface it by saying that many practitioners have different ways of using different materials, I will give you my preferred method but try to be complete as to what others tend to do. Some practitioners do like skin preparation some will prefer banded iron thinking that it will give you a better surface area to adhere to the underpadding, also if there is skin compromise at least you have something that�s disinfected the skin. Some will use tincture of benzoin again for better cast-padding material adhesion. And then some will use lotion because the skin will get dry under the cast and the thought processes keep the skin nice and supple. I don�t use anything, my overall, if I have another credo in Serial Casting, less is more. Along those lines Surgitube, tube gauze, Stockinette doesn�t really matter, I am not advocating any particular brand, but you need some underpadding. I tend not to use it as a full length that is I use one part distally and one part proximally because it�s really in my opinion it�s only there to go over the cast and the cast-padding that you are going to apply. So you don�t get irritation, so you don�t get the child pulling at the, whatever the material might be.

    Now some practitioners will go full length again nothing wrong with that but I feel like its little more material that�s really not necessary. Cast-padding is the next interface between the child limb and the plaster material. Webril and Specialist cast-padding are both brands that are used by many practitioners, I favor Webril because it has a higher tensile strength, but it is a little more coarse, for that reason many practitioners like the Specialist cast-padding which is a little fluffier, easier to work with and softer on the skin. When you are applying it to the body part, I always advocate take it off the body part, pull as hard as you possibly can to get sufficient tension. You are not going to compromise vascularity. You can pull as hard as you want and pull it as tight as you want and that child is not going to have any decrease in capillary filling time.

    When you are pulling it on, it should go against the deformity and we are going to talk about that in Part II, what I mean exactly, but basically you want to go on the opposite direction to the way that pathology of the deformity is. And then when you are applying the cast-padding you want to apply it without wrinkling. If you have wrinkling you are going to get a looseness and possibly oppression necrosis. When you are applying the cast-padding do it when you have attained the final position, you don�t want to apply the padding and then position the limb. As you see here you start getting wrinkling, wrinkling can lead to oppression necrosis, oppression necrosis can lead to a discoloration that can last for up to 6 months and the parents can be very happy with the correction and very unhappy that their child has an ankle that looks like they have got tattoos.

    I like to apply four layers on the proximal and distal aspects for a lot more cushioning, but everywhere else it should be two at the most three layers. You do not want to overpad. With over-padding comes movement, comes lack of correction and ultimately you are not doing anybody a favor. Where sometimes practitioners will underpad is at the heel. So if you need to place another layer at the heel, do it in a U-fashion going from the middle through the heel and lateral malleolus, not interiorly across the ankle joint. And then overlap, I have each turn so that you are getting those double layers very easily and very quickly.

    And then comes the casting itself, the temperature of the water should be warm, shouldn�t be hot, shouldn�t be cold. Cold, it�s going to take a long time to set. Hot it can give you an exothermic reaction which can actually burn the child. As a rule I like extra fast setting plaster and I am not going to name any brands, but I feel that that�s a very good quick setting and inexpensive relative material. There are hybrid plaster fiberglass materials out there now, very easy to apply, don�t need as much but I don�t tend to like them because they are more expensive and a little more difficult for parents to remove. Just as you apply your cast-padding you want to apply the plaster evenly, leaving about a quarter to a half inch of cast-padding three on the proximal and distal ends. So that area is nice and soft and there is no material of plaster that can irritate the child.

    Unlike cast-padding where I said you can pull it as hard as you can, when we are talking about plaster you want to roll it on the limb, I tell students just rolling hand off to yourself, you don�t want to pull it off the limb because there you can end up compromising vascularity if you are not paying attention. So very safe rule is just to role it on, remember you have manipulated and then you have put your cast-padding on which actually holds the limb in a good position. Your plaster should just go on very easily and in that position. After applying the first roll, assume the position and by that I mean you want to go into position that you were manipulating. That roll that first roll is the one that�s really going to set and give us our correction.

    When you are applying pressure you want to avoid decreases with your fingers, you don�t want to high points. And I know in this picture looks like that�s a decrease but if you look at it carefully, its actually over a long surface. If you have had your fingertips pushed in there that leaves a high point under the cast and that could be a source of irritation to the child. When you finish as you go proximally whether it�s a long or short leg cast, leave a little tag as you can see here. That tag that lump will make it easier for the parents to remove the plaster cast later on. And what I actually started doing over the years as I leave a little tag as I am going along, so each roll will have it�s own little tag for the parents to find. And then you want to check and also document the vascularity to the toes, is normal. You strongly don�t want any skin compromise any vascular compromise, but you also if you have checked it, as with any documentation you want to make sure that you record it for any potential legal challenge.

    Then after casting, we want to give very concise instructions to the parents, both verbally and I give them a written sheet. We want them to check the toes and I know some practitioners will tell them to check the toes everyday and there is no harm in that but quite honestly if you are going to get any vascular compromise its probably going to be within the first 24 hours. Monitor for any problems whatsoever and it goes back to our potential contraindications, if the child is fussy and they are either ill or they have had their immunizations, the parents won�t be able to determine. If the child is nice and healthy, if the child is fussy, that�s a possible sign of problems with the casting they should call you immediately. And then the parents are responsible in my opinion for soaking off the cast, before they come back to see you. And I tell them to soak the cast off the night before or hours before they are about to see you. I don�t like to take cast off from babies with a cast saw, I will not hurt the child but that noise and the vibration and potential heat can scare them and if that happens each sequential casting could be a problem as far as that child is concerned. So I tell the parents to do it. Just warm water is fine, some people advocate putting a little vinegar in the water and I tell parents that�s fine it acts little bit as an accelerate but try not to put too much vinegar in because it can be caustic to baby skin.

    As I said earlier you want to try to predict for the parents how long the child is going to be in the cast and also how often the cast are going to be changed. My general rule is under 3 months, I generally would do this weekly. Children grow very rapidly in the first three months and you don�t want them going to getting to be too big for the cast and compromising vascularity in that first three months. If they are older than 3 months or after 3 months if it�s a first time I will initially do a weekly to get the maximum out of change in the shortest period of time. And once I have gotten the pathology somewhat corrected, then I will go to a biweekly casting.

    And then I tell the parents really it should be until we get good correction. And that�s something difficult to say, now with things like calcaneal vargus where its very flexible, you could probably give a very good ballpark when it comes to a moderate to severe, rigid metatarsus adductus or talipes equinovarus, it�s a little more difficult. So I always tell parents I will give you a timeframe but please don�t hold me do it.

    After we have achieved appropriate correction it�s maintenance that really is key. You in all likelihood will have relapse if you don�t use some modality in order to maintain a correction for a longer period of time. Now Dr. Ganley alert your search, I found this attributed to him to maintain it the limb for one and a half times the amount of time it took to affect the correction. This isn�t anything that is scientific but we tend to hold to that standard. At the time Dr. Ganley was a big advocate of further casting for that period of time, but over the years most of us have adopted other modalities to maintain the correction, whether it�s a Dennis Brown Bar or a Dobbs Brace types of shoes with padding without padding and orthosis for long term affect.

    Errors in cast-padding I have alluded to some of them, one is too much cast padding, they are going to move, you get less than optimal results, you may get irritations. Same with loosely applied padding or plaster, particularly with plaster if it�s loosely applied it won�t hold as well, it will break down and it can be a source of irritation. Wrinkling of the materials I covered and then stopping too early, this is probably the number one problem with the early practitioners as Serial Casting. The tendency to feel like you have done enough, the parents you know getting anxious when are you going to stop. And you feel like okay that�s good enough but what ends up happening is it relapses very quickly and you will ultimately be very unhappy and so will the parents.

    Failure to retain the correction that is maintenance, again the thought is, well I have casted and everything is going well, but if you don�t maintain, you could get a pretty significant relapse and it will all have been for not and on the heals of that the failure to monitor for an also aggressively treat the relapse by aggressively I mean you don�t say, well let�s watch and wait or let�s put a pair of shoes on the job, go back start Serial Casting like you did the first time. You have worked very hard to achieve this, the parents have the child has in their own way and why compromise anything by avoiding what you see in your mind.

    Again I keep making the illusions to surgery if after doing HAV surgery you get a hallux varus, you are not going to just sit and watch and wait I hope, you are going to go in and repair it, you will have to incur that look on the you know the patient�s face while you are doing it, but you will be doing the right thing. Same thing if you start seeing relapse with Serial Casting.

    So that concludes Part I of Serial Casting the 21st Century. We have laid the foundation for Serial Casting and all its particulars. In Part II, we are going to be applying these particulars to four pathologies in a cookbook fashion so you can have an understanding of how to manipulate and cast and correct the four major deformities that we can see. Thank you for attention, I look forward to presenting Part II.