First Steps: Orthoses for the Pediatric Foot and Ankle
November 2009 Issue
Seeing a child walk for the first time can be one of life's great joys. Supporting a child in a lifetime of healthy movement can be even better. Clinicians who work to support and control the pediatric foot and ankle face an array of challenges on their way to getting and keeping kids on their feet, including a daunting range of device choices, both off-the-shelf and custom. However, choosing and developing the right device is just one step in the process. Working with children can mean exercising skills usually classed under child psychology, business networking, and even entertainment.
For this article, four experts in pediatric orthotics offer their insights into supporting children's gait through the use of bracing, with thoughts on choosing and developing the right device, casting, troubleshooting, and follow-up. While their statements don't represent all opinions in the profession, their expertise can provide helpful advice on a potentially difficult process.
Custom or Off-the-Shelf?
As manufacturing techniques and knowledge of pediatric gait principles have developed over the past three decades, off-the-shelf pediatric orthoses have begun to take a respected place alongside custom devices. All four practitioners interviewed apply both styles. However, the question of which devices suit which situations remains contentious.
|Doug Reber, CO, LO, keeps pediatric patients like Will Voebel happy by offering a warm attitude and stuffed toys, and by replacing the exam table with a parent's lap.|
"Due to the complexity of the pediatric patient's foot, it is rare that I use off-the-shelf AFOs," says Keith Smith, CO, president of the American Academy of Orthotists and Prosthetists (the Academy), speaking as an individual practitioner and not for the Academy. "The complexity of the placement of the sustentaculum tali push, for instance, can make it difficult to attain [with an off-the-shelf design]...." He contends that off-the-shelf orthoses that control the sagittal plane only, such as the Kinetic Research Noodle, can work well for patients whose only complaint is foot drop, but the majority of patients require more support for coronal plane deformations or the transverse plane. He asserts, "Off-the-shelf SMOs lead to a scenario with too little contact-creating loss of control-or too much contact, which leads to impingement and skin breakdown. All orthotists should consider whether they can optimize fit and comfort without giving up any facet of either of these.... If the answer is no, then a custom design should be the only choice."
Doug Reber, CO, LO, area practice manager at Hanger Prosthetics & Orthotics in Farmingdale, New Jersey, has a patient roster that is about 80 percent pediatric. He considers age and cost, as well as anatomy, when choosing between custom and ready-made. "I would say that kids four years old and under make a great population for off-the-shelf products. We know that they're going to grow quickly...so cost and insurance factors come in, as well as growth factors.... A lot of new off-the-shelf products work great with...pudgy little feet or low-tone feet because you have a lot of compression and play to align them."
Some orthotists also choose off-the-shelf devices for older children who are extremely difficult to cast. Debbie Donaldson, CPO, manager of the Mt. Vernon, Washington, office of Cascade Prosthetics & Orthotics (allied with Cascade DAFO), says, "If patients have such high sensory issues that...even measurement is tricky, I would consider an off-the-shelf brace just to get them used to having something on their foot."
Choosing Off-the-Shelf Devices
Should a practitioner elect for an off-the-shelf option, certain characteristics may provide the best results for children.
Donaldson says, "For the birth to age-three population...I look for an ankle-foot orthosis with a V-cut in the back so the child can still crawl, and it won't restrict plantar- or dorsiflexion-something thin and flexible that wraps around, that holds the foot in good position without restricting too much motion."
Reber cautions that even the best off-the-shelf device requires modification. "You may have to trim it, adjust it, or add pads to semi-customize it.... We range the foot into plantar- and dorsiflexion to make sure that those top trim lines do not rub into the skin, and we trim the plastic proximal to the metatarsal heads to allow free flexion of the ball of the foot."
Developing a Custom Solution
Orthotic care doesn't begin and end with a brace. Especially when developing custom orthoses, working with allied care providers and families to address the psychological and physical needs of the patient becomes paramount.
Curt Bertram, CO, area practice manager of the Hanger Prosthetics & Orthotics office located at the Children's Hospital of Wisconsin, Milwaukee, says, "I see the patient for an hour, maybe 45 minutes. That's not much time, so the more therapy notes, notes from physicians, and information from the parents I can get, the better my decision-making will be."
According to Smith, the foundation of a quality custom device "is in the care that is given to ensure a good cast mold of the patient. All three planes should be controlled well in the cast." For example, for an equinovarus foot, the clinicians in his company use a Sabolich lateral trimline and keep the first met head encompassed by the medial wall. "The force is used to abduct the forefoot while you use the opposing hand proximal to the lateral malleolus to correct the varus deformity. [My] best tip is to use all fingers of both hands in the cast mold to get as much contact in the critical areas as possible."
However, good casting may be as much about the child as it is about the materials.
"I usually try to involve the child as much as possible," Donaldson says. "If I have them seated, I have them on a bench where they can see what I'm doing. I let them pick colors-though when some kids with high tone start to use their hands, their feet go into their worst position. When I'm casting, I may have them set the colors aside and have 'quiet hands.' I'll have them tell me a story or maybe we'll just breathe slowly together."
Bertram also avoids using a casting saw. "We use kind of an oversized cut strip-we put it in the cast, pull it out, and it creates a well. Then we use tiny surgical scissors that don't have a point on them-they can cut right at the dorsum."
Smith says, "I always spend the first five minutes getting to know the kiddo. After the introduction, I only talk to the kiddo, as if the parents are not there. I call them 'Buddy' or talk about how they could be a princess. The key is you must become a friend in that first five minutes because if you don't, you will have a bad mold because you have a tough kid to mold. Fortunately, I am also a magician, so...most kiddos leave saying that they can't wait to come back for the next visit to see another magic trick."
Design, Fitting, and Follow-Up
|Debbie Donaldson, CPO, encourages children to be curious about every step of the exam and casting process.|
Though the clinical functions of a brace depend on the patient's individual anatomy, other considerations can inform brace design as well.
Reber's clinic considers each family's "gadget tolerance." Families that are already overwhelmed with other concerns may fail to apply a complicated device correctly, or at all. "If I have a family that I know is at their wit's end," he says, "we want to make it as simple as possible for them, so I'm not going to design [the brace] so that it has all kinds of bells and whistles on it."
He also feels strongly that "you don't just send a child out and not see them for a year and a half until they've outgrown the brace. There are a lot of things you can do to enable the product to last longer and the user to be more comfortable." He recommends monitoring the quality of Velcro and any internal padding over prominent bones. He notes, "As children grow, their calves get wider, so you can heat and flare the device to buy some time."
Smith says that in follow up, "the most common problem is the navicular bone rubbing as the patient grows. This usually happens when the arch no longer fits, allowing the midfoot to collapse into the wall. The most common error is for the orthotist to simply flare out the navicular without paying attention to the arch." He also notes that orthotists should remember the key components for the particular patient's diagnosis and presentation. For example, a child with foot drop and no other issues whose toes grow distal of the footplate could simply have the footplate trimmed toe sulcus.
Bertram concludes, "Kids aren't little adults. Working with them requires a subspecialty and a passion to do it. You have to want to do it-you're not only working with a child but with a family, plus your network of physician referrals and therapists." Combining these considerations, plus clinical knowledge, can mean big successes for even the littlest patients.
Morgan Stanfield can be reached at
Casting the Very Difficult Patient
Over the course of their careers, orthotists who work with children are likely to encounter at least a few patients who are combative or otherwise highly challenging to measure and cast due to cognitive issues, fear of medical procedures, or other problems. Below, four pediatric specialists offer their insights into helping these challenging kids get the orthotic care they need.
"Having a child who physically couldn't be casted-and that does happen-would be a consideration for an off-the-shelf device. I don't like to recommend sedation for a child although I have done it a handful of times over the years due to requests from the parents and the physician." -Curt Bertram, CO, area practice manager of the Hanger Prosthetics & Orthotics office located at the Children's Hospital of Wisconsin, Milwaukee.
"I usually talk calmly, move slowly, and a lot of times I'll watch them walk around with their parent first. When I manipulate the feet, sometimes I'll keep their socks on because that reduces their sensitivity-they have more of a barrier, and they may not feel quite as exposed." -Debbie Donaldson, CPO, manager of the Mt. Vernon, Washington, office of Cascade Prosthetics & Orthotics (allied with Cascade DAFO, Mt. Vernon, Washington).
"For kids who have significant cognitive problems, we encourage the family to be there. In a school setting, the therapist knows the idiosyncrasies of the child-whether they like music or if they like to tap. One of the key things is the environment that they're in. You need to put the child in a comfortable environment. They are going to be a lot more relaxed, which enables you to be able to get your measurements or cast a lot easier. I have a specialized fitting room with about 150 stuffed animals, and we let the kids hold them. And something as simple as the tone of voice of the practitioner can make a difference, whether the practitioner has a loud rough voice or a soothing voice." -Doug Reber, CO, LO, area practice manager at Hanger Prosthetics & Orthotics in Farmingdale, New Jersey.
"For those kiddos who generally have a hard time with being cast, such as patients with autism, I find it important to see them in one of their 'comfort zones' such as their home or school. DVDs are also extremely helpful. It is also important to realize that going with an off-the-shelf design because of difficulty in casting will lead to a poor outcome because the combative patient is also typically combative during brace fitting. A good fit with a custom mold is essential-the better the cast, the better the brace; the better the brace, the happier the patient and mom; the happier the patient and mom, the happier the orthotist. It's that simple." -Keith Smith, CO, LO, FAAOP, Orthotic & Prosthetic Lab, St. Louis, Missouri.