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Dr. Taral Nagda
Paediatric Orthopaedic Surgeon

 
     
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Patient's Information
Clubfoot
 
ARTICLES
 
Details of the the Ponseti Technique
Cast Application, Molding, and Removal
Equinus Correction and Fifth Cast
Bracing
Managing Relapses
Instructions for Brace Use
Overview of Ponseti Management
Common Questions
LINKS
CASE DISCUSSIONS
PATIENT'S REVIEW
 
CAST APPLICATION, MOLDING, AND REMOVAL
 
Success in Ponseti management requires good casting technique. Those with previous clubfoot casting experience may .nd it more diffcult than those learning clubfoot casting for the first time.
 
We recommend that plaster material be used because the material is less expensive and plaster can be more precisely molded than .berglass.
 
STEPS IN CAST APPLICATION
 
PRELIMINARY MANIPULATION
  Before each cast is applied, the foot is manipulated [A].
 
APPLYING THE PADDING
  Apply only a thin layer of cast padding [B] to make possible effective molding of the foot. Maintain the foot in the maximum corrected position by holding the toes while the cast is being applied.
 
APPLYING THE CAST
  First apply the cast below the knee and then extend the cast to the upper thigh. Begin with three to four turns around the toes [C], and then work proximally up the leg. Apply the plaster smoothly. Add a little tension [D] to the turns of plaster above the heel. The foot should be held by the toes and plaster wrapped over the "holder.s" .ngers to provide ample space for the toes.
 
MOLDING THE CAST
  Do not try to force correction with the plaster. Use light pressure. Use light pressure.
   
  Do not apply constant pressure with the thumb over the head of the talus; rather, press and release repetitively to avoid pressure sores of the skin. Mold the plaster over the head of the talus while holding the foot in the corrected position [E]. Note that the thumb of the left hand is molding over the talar head while the index .nger of the left hand is molding above the calcaneus. The arch is well molded to avoid .atfoot or rocker-bottom deformity. The index .nger of the right hand is maintaining the correction. There is no pressure over the calcaneus. The calcaneus is never touched during the manipulation or casting. Molding should be a dynamic process; constantly move the .ngers to avoid excessive pressure over any single site. Continue molding while the plaster hardens.
 
EXTEND CAST TO THIGH
  Use much padding at the proximal thigh to avoid skin irritation [F]. The plaster may be layered back and forth over the anterior knee for strength [G] and for avoiding a large amount of plaster in the popliteal fossa area, which makes cast removal more dif.cult.
 
TRIM THE CAST
  Leave the plantar plaster to support the toes [H], and trim the cast dorsally to the metatarsal phalangeal joints, as marked on the cast. Use a plaster knife to remove the dorsal plaster by cutting the center of the plaster .rst and then the medial and lateral plaster. Leave the dorsum free. Note the appearance of the .rst cast when completed [I]. The foot is in equinus, and the forefoot is fully supinated.
 
CAST REMOVAL
 
Remove each cast in clinic just before a new cast is applied. Avoid cast removal before clinic because considerable correction can be lost from the time the cast is removed until the new one is placed. Although a cast saw can be used, use of a plaster cast knife is recommended because it is less frightening to the infant and family and also less likely to cause any accidental injury to the skin. Soak the cast in water for about 20 minutes, and then wrap the cast in wet cloths before removal. Use the plaster knife [A], and cut obliquely [B] to avoid cutting the skin. Remove the above-knee portion of the cast .rst [C]. Finally, remove the below-knee portion of the cast [D].
 
DECISION TO PERFORM TENOTOMY
 

A major decision point in management is determining when suf.cient correction has been obtained to perform a percutaneous tenotomy to gain dorsi.exion and to complete the treatment. This point is reached when the anterior calcaneus can be abducted from underneath the talus. This abduction allows the foot to be safely dorsi.exed without crushing the talus between the calcaneus and tibia [E]. If the adequacy of abduction is uncertain, apply another cast or two to be certain.
 
CHARACTERISTICS OF ADEQUATE ABDUCTION
Con.rm that the foot is suf.ciently abducted to safely bring the foot into 15 to 20 degrees of dorsi.exion before performing tenotomy.
 
The best sign of suf.cient abduction is the ability to palpate the anterior process of the calcaneus as it abducts out from beneath the talus.
 
Abduction of approximately 60 degrees in relationship to the frontal plane of the tibia is possible.
 
Neutral or slight valgus of os calcis is present. This is determined by palpating the posterior os calcis.
 
Remember that this is a three-dimensional deformity and that these deformities are corrected together. The correction is accomplished by abducting the foot under the head of the talus.
 
THE FINAL OUTCOME
 
At the completion of casting, the foot appears to be overcorrected into abduction with respect to normal foot appearance during walking. This is not in fact an overcorrection. It is actually a full correction of the foot into maximum normal abduction. This correction to complete, normal, and full abduction helps prevent recurrence and does not create an over-corrected or pronated foot.
 
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