I’m a Technician, Not a Magician
The phrase "work your magic" is both a compliment and a curse. On one hand, it is a tremendous vote of confidence when someone clearly believes I have the skill, experience, wisdom, or whatever to turn a bad cast into a functional orthosis. On the other hand, I know who is hiding behind the curtain, and it's just me. Yes, I have been doing this for a long time, and yes, I have seen a lot over the years. But, no, I am not in possession of any extraordinary powers. I know a lot of people who also have been doing this for so long that their skill, experience, wisdom, or whatever gives them the appearance of possessing magic powers as well, but sadly they don't have magic powers either. The cold, cruel fact of the matter is that most of us just do the best we can.
When it comes right down to it, it only takes three things to make a great orthosis: a great cast, accurate measurements, and clear instructions.
If I don't have a great cast, I can still make a brace—not a great brace, but a brace nonetheless. I've wrapped a few casts over the years, and not all of them were "great." I realize that this is going to happen. Sometimes the patient is uncooperative, sometimes the casting environment is less than ideal, and sometimes it's just an off day. It's not the end of the world. I have learned to make corrections that will allow me to still net a positive end product. Sometimes, however, the difficulties are too great to overcome.
In the central fabrication business, we see everything from the best of the best to the completely unusable. The vast majority are somewhere in between. The key point to remember is that the people who send us the best casts also tend to enjoy the lowest redo rates. I tell orthotists all the time: "Your job is to take a perfect cast, and my job is not to screw it up!" The closer the original mold is to the desired shape and angulations of the finished product, the less I have to guess at it. If I have to make gross angular adjustments or move tissue around to normalize the shape, I have to make some substantial assumptions. The biggest assumption is that the shape of the limb is "normal." The fact of the matter is that people with normal physiology rarely come to see an orthotist.
While I'm divulging my secrets, here's another one. I don't need measurements. That's right folks, you heard me correctly: I don't need measurements because I don't have to fit the brace—but orthotists do! Most technicians will be happy to guess at it if you want them to, but when an orthotist has to walk into the fitting room, those measurements take on a whole new meaning. Let's face it—if I have accurate measurements, I can do a better job of dialing in the fundamentals such as knee center, thigh circumference, and foot length. All these things can ruin a brace if I get them wrong, but if I've been given a great cast, this usually is not an issue.
Charcot Restraint Orthoses (CROs) are a perfect example. These devices are generally built for people with some history of volume fluctuation and, similar to prostheses, they are usually total contact. Depending on the time when the cast is taken and the length of time required to fabricate the device, there can be a significant volume change in the affected limb. So you cast the limb, we fabricate the device, you fit the device, and I get the call.
"This CRO is too tight." Or, "This CRO is too loose. What did you guys do?" I ask, "How does the patient compare to the original measurements?" The answer? "We don't take measurements; we just go by the cast."
The fact of the matter is, we rarely add or remove a lot of material during modification, and certainly not the amount it would take to make a gross difference. So how do you know what led to an ill-fitting device? The short answer is, without measurements, you can't. Not only can we not tell whether the patient changed or not, we also cannot tell whether we over-modified the mold. So what do you do? Do you re-fabricate the device only to find at the next fitting that the patient has once again changed volume? Do you try to adjust the device and instruct the patient on how to regulate his or her volume? Accurate measurements make it instantly apparent where the problem is and provide a clear course of action to correct it.
Last but not least, if you want an orthosis that not only fits but functions and meets the patient's needs, you have to tell me what you want! I'm still stunned by how many casts I get with just a business card stapled on the side of it. No notes, no nothing. Don't get me wrong. Having to stop what I'm doing to call a practitioner and get fabrication instructions doesn't bother me at all. On the contrary, talking to my friends in the business is one of my favorite parts of my job. The problem is that in the time it takes for the device to go through your in-house systems and travel to our facility, there is a good chance you will have forgotten a lot of the critical details about your interaction with the patient and about the subtle nuances you discovered during that interaction, and that means a lost opportunity. It's easy to miss a critical detail, and having to remake an orthosis because a minor detail was forgotten not only wastes your time and money, it also wastes your patient's time and money.
I realize that sometimes we can get caught up in the business of selling orthoses and prostheses, but really, our job is to change lives—to do everything in our power to help our customers realize the greatest possible increase in their quality of life. To meet that mandate, we all have to do our best. We have to slow down, understand our patient's needs, take some notes, take as good a cast as we possibly can, and take accurate measurements—in short, live up to our own image of what we would want from someone in our profession.
So remember, unless you are a magician capable of fixing whatever I throw at you, realize that I probably can't fix whatever you throw at me.
Tony Wickman, CTPO, is the CEO of Freedom Fabrication, Havana, Florida. He can be reached at