prosthetics and orthotics manufacturing guidelines: lower limb orthotics: patellar tendon-bearing...
TRANSCRIPT
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Physical Rehabilitation Programme
Patellar
tendon-bearing orthosis
Manufacturing guidelines
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Tb o cott
Foreword 2
Introduction 4Choosingbetweentwomethods 4
1.Castingandrectication 5
2.PBOwithanterior-closingshell 6
2.1EVApreparationorincreasedweightrelie 6
2.2MouldingoEVA 7
2.3Orthosistrimline 8
2.4Plasticreinorcement 9
2.5Posteriorshell 10
2.6.Anteriorshell 12
2.7Preparationorinitialtting 14
2.8Initialttingandnishing 17
3.PBOwithposterior-closingshell 19
3.1EVApreparationorincreasedweightrelie 19
3.2MouldingoEVA 20
3.3Orthosistrimline 21
3.4Plasticreinorcement 22
3.5Anteriorshell 22
3.6Posteriorshell 25
3.7Preparationorinitialtting 26
3.8Initialttingandnishing 27
Listomanuacturingmaterials 28
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Forwor
T ICRC poypropy tcooy
Sinceitsinceptionin1979,theICRCsPhysicalRehabilitationProgrammehaspromotedtheuseotechnologythatisappropriatetothespeciccontextsinwhichtheorganizationoperates,i.e.,countriesaectedbywarandlow-incomeordevelopingcountries.
Tetechnologymustalsobetailoredtomeettheneedsothephysicallydisabledinthecountriesconcerned.
Tetechnologyadoptedmustthereorebe:
durable,comortable,easyorpatientstouseandmaintain; easyortechnicianstolearn,useandrepair; standardizedbutcompatiblewiththeclimateindierentregionsotheworld; low-costbutmodernandconsistentwithinternationallyacceptedstandards; easilyavailable.
Techoiceotechnologyisogreatimportanceorpromotingsustainablephysicalrehabilitationservices.
Forallthesereasons,theICRCpreerredtodevelopitsowntechniqueinsteadobuyingready-madeorthopaediccomponents,whicharegenerallytooexpensiveandunsuitedtothecontextsinwhichtheorganizationworks.TecostothematerialsusedinICRCprostheticandorthoticdevices
islowerthanthatothematerialsusedinappliancesassembledromcommercialready-madecomponents.
WhentheICRClauncheditsphysicalrehabilitationprogrammesbackin1979,locallyavailablematerialssuchaswood,leatherandmetalwereused,andorthopaediccomponentsweremanuacturedlocally.Intheearly1990stheICRCstartedtheprocessostandardizingthetechniquesusedinitsvariousprojectsaroundtheworld,orthesakeoharmonizationbetweentheprojects,butmoreimportantlytoimprovethequalityoservicestopatients.
Polypropylene(PP)wasintroducedintoICRCprojectsin1988orthemanuactureoprostheticsockets.Terstpolypropyleneknee-jointwasproducedinCambodiain1991;othercomponents
suchasvariousalignmentsystemswererstdevelopedinColombiaandgraduallyimproved.Inparallel,adurableoot,madeinitiallyopolypropyleneandEthylVinylAcetate(EVA),andnowopolypropyleneandpolyurethane,replacedthetraditionalwooden/rubberoot.
In1998,aercareulconsideration,itwasdecidedtoscaledownlocalcomponentproductioninordertoocusonpatientcareandtrainingopersonnelatcountrylevel.
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Objctiv o t mu
TeICRCsManuacturingGuidelinesaredesignedtoprovidetheinormationnecessaryorproductionohigh-qualityassistivedevices.
Temainaimsotheseinormativemanualsareasollows:
opromoteandenhancestandardizationoICRCpolypropylenetechnology; oprovidesupportortrainingintheuseothistechnology; opromotegoodpractice.
Tisisanothersteporwardintheeorttoensurethatpatientshaveaccesstohigh-qualityservices.
ICRCAssistanceDivision/HealthUnitPhysicalRehabilitationProgramme
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Cooi btw two mto
Teollowingindicationsmighthelpinmakingachoicebetweenthetwopossiblemethods.
Wit ri: prti or compt?
Accordingtotheprescriptionand/orthepathology,theorthosismustpartiallyorcompletelyrelievetheweightappliedontheleg.
othisend,alayeroEVAisaddedundertheootpriortothedrapingothepolypropylene.
Teollowingguresgivearoughestimateothedegreeoweightrelie:
NoEVA:70%otheweightonthelegand30%ontheorthosis. 3mmEVA:50%onthelegand50%ontheorthosis. 6mmEVA:30%onthelegand70%ontheorthosis. 12mmEVA:0%onthelegand100%ontheorthosis.
Itrouctio
Teaimothisdocumentistodescribetwomethodsorproducingpatellar tendon-bearing (PTB)orthoses,workingwiththeICRCpolypropylenetechnologyandorthopaediccomponentsusedat
theICRCsphysicalrehabilitationcentres.
Anterior-closing shell Posterior-closing shell
Weak at ankle level, especially or heavy
patients or patients walking with ankle
dorsiexion.
Strong at ankle level, thus suitable or
overweight patients or patients walking with
ankle dorsiexion.
Easy to t into normal shoes.
Sometime difcult to t into normal shoes
because o the volume o the orthosis at
mid-oot.
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Patientassessment,castingandrecticationopositivecastimpressionsareperormedinaccordancewithprostheticandorthotic(P&O)standards,takingintoaccounttheollowingpoints: Teproximalpartismanuacturedlikeatrans-tibialprosthesisandensurestheweight-bearing
unction. Tedistalpartismanuacturedlikeanankle-ootorthosis. Teremustbelittleornoweightborneonthelegwhilethecastisbeingtaken. Inthemethodinvolvingaposterior-closingshell,theEVAusedtoincreaseweightrelieisplacedonlyundertheheel,soitafects the position o the cast(seesection3.1,page19).
CasTIng and ReCTIF ICaTIOn1
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2.1 eVa prprtio or icr wit ri
Followtheproceduredescribedbelow,orgoontothenextsectionithepatientdoesnotrequire
additionalweightrelie.
PTBO WITh anTeRIOR-ClOsIng shell2
4PlacetheplastermodelontheEVAsheetanddrawalinearoundit1cmwiderthantheoot.
4Holdtheplastermodelinavice.
HeattheEVAat120or3to5minutes,dependingonitsthicknessandontheeciencyotheoven.
PuttheEVAundertheootandholditrmlyinplacewithanelasticbandageoroneminute.
GrindtheedgeotheEVAuntilitisperectlyalignedwiththeshapeotheplastermodel.
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6GluetheEVAundertheplastermodel.
2.2 Moui o eVa
EVA(6mm)canbemouldedpriortodrapingothepolypropylene: toimprovecomort; topreventskinbreakageinpatientswithsensationloss.
Followtheproceduredescribedbelow,orgoontothenextsectioniEVAisnotrequired.
4Positiontheplastermodelwiththeoreootpointingdownwards.
CutapieceoEVA: width,kneecircumerence; length,thelengthotheplastermodel(leg+oot);
thickness,6mm.
HeattheEVAat120or3to5minutes,dependingontheeciencyotheoven.
DrapetheEVAovertheplastermodelmanuallyandholditinplaceuntilithascompletelycooled.
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2.3 Ortoi trim i
4Cutotheexcesswithacutterorapairoscissors.
StapletheEVAontotherontotheplastermodel.
4Marktheorthosistrimlineasollows:
A Tetopmustbehorizontal,6cmabovethepatellatendongroove.
B Tepatellaandthehamstringtendonsareleree.
C Teshelloverlapstheantero-posteriormid-lineby1.5cm.
D Attheankle,keeptheline1cmanteriortothetopothemalleoli.
E Teusualdistallimitotheanteriorshellishorizontal,at1/3othelengthotheleg,butmaybelongertoprovide
greaterprotection.
F Attheoreoot,clearthesidesothetoesandtheheadothemetatarsuscompletely,passingbeneaththem.Tiswill allow the polypropylene to ollow themovement o the metatarso-phalangeal
joints.
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2.4 Ptic riorcmt
Teorthosismayneedreinorcement,especiallyatanklelevel.Ithisisthecase,ollowoneotheproceduresdescribedbelow;otherwisegoontothenextsection.
2.4.1 doub yr o poypropy
4Asecondlayeropolypropylenecoveringtheankleandtheootismouldedatthesametimeasthemainlayer.
Cutapieceopolypropylene: thickness,3mm; width,instepcircumerence;
length,lengthooot+10cm.
Grindthelast3cmattheproximalendtograduallyreducethethicknessothepolypropylene.
4Tetwolayersareheatedatthesametime.
Tereinorcementisplacedontheplastermodel,thenthesecondlayerisvacuum-mouldedimmediatelyaerwardstoobtainaperectsealbetweenthetwolayers.
Te double layer o polypropylene has the disadvantage o reducing exibility o the oreoot in relationto the metatarso-phalangeal joint.
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2.4.2 ltr riorcmt (c)
4CuttwobandsoEVA: thickness,6mm; width,7mm;
length,15cm.
Pullastockingovertheplastermodel.
Gluethebandlightlyontothestocking.
Te more anterior the position o thechannel, the more the device will resistdorsiexion o the ankle.
Reinorcements prolonged along the side
o the mid-oot increase the volume othe orthosis so that it may no longer tinto the patients shoe.
2.5 Potrior
2.5.1 Vcuum moui o poypropy
Ithishasnotalreadybeendone,pullastockingovertheplastermodel.For maximum eciency, theEVA used to channel the polypropylene must not be covered with a stocking.
Dustthestockingwithtalcumpowder.
Measurementothepolypropylenesheet:
Kneecircumerence+10cm. Instepcircumerence+10cm. Legandootlength+10cm.
Tickness,4mmor5mm,dependingonthepatientsweight.
2
1
3
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Heatthepolypropyleneat180or20to25minutes,dependingonthethicknessothepolypropyleneandtheeciencyotheoven.
Drapethepolypropyleneovertheplastermodelandstickittogetheralongtheanteriorside.
ightenthepolypropylenearoundthesuctionconewitharopeorsomethingsimilar.
Openthevacuumvalve.
4Cutotheexcesswithapairoscissorswhilethepolypropyleneisstillhot.
2.5.2 Prprtio o t potrior
Drawthetrimlineonthepolypropyleneasexplainedinsection2.3(page8).
Cuttheorthosiswithanoscillatingsaw,ollowingtheoutline.
Removetheshellgentlytoavoiddamagingtheproximalpartotheplastermodel,asitwillbeusedtomouldthesecondshell.
Removethestockingrominsidetheorthosis.
Grindthetrimlineandsmoothit.
IanEVAhasbeenmoulded,transerthetrimlinetotheEVAandcutotheexcesswithapairoscissors.
Beore moulding the second shell,keep an angle o 90 at the cornero the anterior/proximal trim linebecause a rounded shape wouldcreate a notch in the polypropyleneo the posterior shell which might
prevent proper unctioning o the
hinged joint.
Keepthevacuumonuntilthepolypropylenecoolsdown.
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2.6 atrior
Repairtheproximalpartotheplastermodelinecessary.
2.6.1 Moui eVa
oimprovecomort,6mmEVAcanbemouldedpriortodrapingothepolypropylene,whetherornotthesamehasbeendoneortheothershell.
Followtheproceduredescribedbelow,orgoontothenextsectioniEVAisnotrequired.
4CutapieceoEVA6mmthickandlargeenoughtocovertheproximalhalotheplastermodel.
HeattheEVAat120or3to5minutes,dependingontheeciencyotheoven.
PuttheEVAovertheplastermodelandholdittightlyinplacewithanelasticbandageoroneminute.
4RemovetheEVAandcutit,ollowingthetrimline.
akethepolypropyleneshell(withitsEVA)andxthenewlymouldedEVAwithtwostaplesclosetotheproximal/medialtrimline.
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2.6.2 Vcuum moui o poypropy o t trior
4GlueastripoEVA6mmthickand3cmwidearoundthemiddleotheplastermodel.Te polypropylene
draping will stop at this level, wherethe rope tightened around the EVA willensure a sucient vacuum.
GlueanotherstripoEVA6mmthickand3cmwideonthemiddleotherstpolypropyleneshellatrightanglestotherststrip.Tis will allow the
polypropylene to be cut afer drapingwithout damaging the shell beneath.
Coverwithastockingtheareareceivingthepolypropylene.Do not cover the strip o EVA where therope will be tightened because the vacuum may leak through the stocking mesh.
Placetheplastermodelwiththeoreootpointingupwards.
Dustthestockingwithtalcumpowder.
Cutapieceopolypropylene: width,kneecircumerence+5cm; length,haltheleglength+10cm; thickness,4mmor5mm,dependingonthepatientsweight.
Heatthepolypropyleneat180or15to20minutes,dependingonthethicknessothepolypropyleneandtheeciencyotheoven.
4Drapethepolypropyleneovertheplastermodelandstickittogetheralong
thelongitudinalstripoEVA.
ightenthepolypropylenearoundthesuctioncone.
Openthevacuumvalve.
Cutotheexcesswithapairoscissorswhilethepolypropyleneisstillhot.
Keepthevacuumonuntilthepolypropylenecoolsdown.
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2.6.3 Prprtio o t trior
Drawthetrimlineonthepolypropyleneasexplainedinsection2.3(page8).
CutcareullyalongtheEVAstripinthemiddleotheposteriorshellwithanoscillatingsaw.
Removetheposteriorshellromtheplastermodel.
Removethestockingrominsidetheorthosisandcutotheexcesswithajigsaw.
Grindthetrimlineandsmoothit.
IanEVAsheethasbeenmoulded,transerthetrimlinetotheEVAandcutotheexcesswithapairoscissors.
2.7 Prprtio or iiti ftti
2.7.1 Prprtio o t i joit
4
SecurethetwoshellsontheplastermouldwithScotchtape.
Markthepositionothehingedjointonthelateralandmedialsides: 4.5cmabovethepatellartendongroove;
inthemiddleotheantero-posteriordiameter.
Makesurethatthehingedjointson
bothsidesareatthesamelevel.
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4Drillahole3mmindiameterthroughbothshells.
4
Assembletheanteriorandposteriorshellswith2slottedscrewsandnuts3mmindiameter(headinside).
Cutandgrindtheboltprotrudingromthenut.
2.7.2 Proxim trp
Useaready-madeVelcrostrap25mmwide,ormakeastrapwithnylonwebbingorsomeotherstrongmaterial.
4Withatubularrivet,xthebeltholdingthelooponthemedialsideotheposteriorshell,atthedistallimitotheanteriorshell.
Teloopshouldbelocated5mmromtheanteriorshell.
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4Insertthebeltthroughthelooptomeasurethelength.
Fixthestrapwithatubularrivetonthelateralside.
Makesurethestrapisperectlyhorizontalbeorexingit.
2.7.3 dit trp
Tisstrapisnotalwaysneeded.Tedecisiontoinstallitorotherwisewilldependonthecapacityothepatientsshoetoholdtheootinsidetheorthosis.
Usea25mmVelcrostrap.
4Withalargetubularrivet,xthebeltholdingthelooponthemedialside,4cmabovethemalleoli.
Teloopshouldbeplacedonthepolypropyleneandnotbeincontactwiththe
patientsleg.
4Fixthestrapwithalargetubularrivetonthelateralside.Makesurethestrapisperectly
horizontalbeorexingit.
Coverthesuraceothestrapincontactwiththepatientslegwith3mmEVA.
2.7.4 Prprtio o t eVa
IEVAisused,glueittemporarilyinsidetheorthosis.
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2.8 Iiti ftti fii
4Tepatientputsontheorthosisbyopeningtheanteriorshellandslidinghis/herootthroughtheproximalend.
TeinitialttingisperormedinaccordancewithP&Ostandards,takingtheollowingpointsintoaccount.
Shouldthepatientslegslipthroughthebrim,theproximalpartcanbepaddedwithEVAtodecreaseitswidth.
Whilethepatientisstanding,checkthedegreeoweightrelie. Aheellionthecontrolateralsidemightbeneededtoaccommodatetheincreaseinlengthothelegwiththeorthosis.
2.8.1 Fiii o t poypropy
4Roundothecornersobothanteriorandposteriorshells.
Carryoutanymodicationsrequiredonthepolypropyleneandsmooththetrimline.
GluetheEVAcompletelyinsidethepolypropylene,cutotheexcessandsmooththetrimline.
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2.8.2 Fiii o t i joit
Usetwocopperrivets3mmindiameterwithtwobrassorstainlesssteelwashers.
Removethe3mmboltononesideoeachrivet.
Heatthecopperrivetwithaweldinggunandstampitsheadintothepolypropyleneotheanteriorshellinordertocreatedepressionstocountersinktherivethead.
4Placetherivetheadonananvilandhammergentlyonthepartotherivetprotrudingromthewasherinordertocreateasmooth,roundedshapeasshownonthepicture.Usearivetsettoroundito.
Inserttherivet,headinside,andinstallthewasheroutside.
Cuttherivetwithdouble-actioncuttingpliersorside-cuttingplierssothatonly2mmprotrudesromthewasher.
Dothesameortheotherside.
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PTBO WITh POsTeRIOR-ClOsIng shell3
3.1 eVa prprtio or icr wit ri
Te EVA is placed only under the posterior part o the oot, in order to avoid an increase in volume at
the mid-oot which may prevent the patient rom wearing normal shoes.
Followtheproceduredescribedbelow,orgoontothenextsectionithepatientdoesnotrequireadditionalweightrelie.
4PlacethemetatarsalheadotheplastermodelattheedgeotheEVAsheetanddrawalinearoundit1cmwiderthantheoot.
4Holdtheplastermodelinavice.
HeattheEVAat120or3to5minutes,dependingonthethicknessotheEVAandtheeciencyotheoven.
PuttheEVAundertheposteriorpartotheootandholditrmlyinplaceoroneminutewithanelasticbandage.
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GrindtheedgeotheEVAuntilitisperectlyaligned,aroundandbelow,withtheshapeotheplastermodel.
6GluetheEVAundertheplastermodel.
3.2 Moui o eVa
EVA(6mm)canbemouldedpriortodrapingothepolypropylenetoimprovecomort.
Do not cover the oot, as this would create an increase o volume which might prevent the patient romwearing normal shoes.
Followtheproceduredescribedbelow,orgoontothenextsectioniEVAisnotrequired.
Placetheplastermodelwiththeoreootpointingupwards.
4CutapieceoEVA: width,kneecircumerence; length,leglength;
thickness,6mm.
HeattheEVAat120or3to5minutes,dependingontheeciencyotheoven.
DrapetheEVAovertheplastermodelmanuallyandholditinplaceuntilithascooledcompletely.
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4Cutotheexcesswithacutterorapairoscissors.
Grindthedistaltrimlinetograduallyreduceitsthickness.
StapletheEVAontothebackotheplastermodel.
3.3 Ortoi trim i
4Markthetrimlineasollows:
A Tetopmustbehorizontal,6cmabovethepatellatendongroove.
B Tepatellaandthehamstringtendonsareleree.
C Teshelloverlapstheantero-posteriormid-lineby1.5cm.
D Attheankle,thelinemustremainabovethemalleolitoacilitatedonning.
E Teusualdistallimitotheposteriorshellishorizontal,at1/3othelength
otheleg,butitmaybelongertoprovidegreaterprotection.
F Attheoreoot,clearthesideandthetopothetoesandtheheadothemetatarsuscompletely,passingbeneaththem.Tis will allow the polypropyleneto ollow the movemento the metatarso-phalangeal joints.
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3.4 Ptic riorcmt
Lateralreinorcements(channels)signicantlyimprovethestrengthotheorthosis.Tereareseveralwaysomakingthesereinorcements.
4CuttwostripsoEVA: width10mm; length20cm; thickness,6mm.
Grindbothdistalandproximalendstograduallyreducetheirthickness.
Gluethestripsontotheplastermodel,1cmanteriortothelateralandmediallongitudinalaxis.
Reinorcements prolonged along the sideo the mid-oot increase the volume o theorthosis so that it may no longer t into the
patients shoe.
3. 5 atrior
3.5.1 Vcuum moui o poypropy
Te procedure described below ensures uniorm thickness o the polypropylene all over the orthosis. Donot try to make a single seam on the anterior side, because the creases gathering at ankle level will makeit necessary to stretch the polypropylene too thinly.
Ithishasnotyetbeendone,pullastockingovertheplastermodel.For maximum eciency the EVAused to channel the polypropylene must not be covered with a stocking.
Dustthestockingwithtalcumpowder.
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1
3
Manufact uring Guid el ines P at el lar Tend on-Bearing Ort hosis
Measurementothepolypropylenesheet:
Kneecircumerence+10cm. Instepcircumerence+10cm. Legandootlength+10cm.
Tickness,4mmor5mm,dependingonthepatientsweight.
Heatthepolypropyleneat180or20to25minutes,dependingonthethicknessothepolypropyleneandtheeciencyotheoven.
Drapethepolypropyleneovertheplastermodelandstickittogetheralongtheposteriorsideand
undertheoot.
ightenthepolypropylenearoundthesuctioncone.
Openthevacuumvalve.
4Cutotheexcesswithapairoscissorswhilethepolypropyleneisstillhot.
Keepthevacuumonuntilthepolypropylenecoolsdown.
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3.5.2 Prprtio o t trior
Drawthetrimlineonthepolypropyleneasexplainedinsection3.3(page21).
Cuttheorthosiswithanoscillatingsaw,ollowingtheoutline.
oremovetheshell,itmightbenecessarytobreakthedistalpartotheplastermodelbelowtheankle.However,caremustbetakennottodamagetheproximalpart,whichisneededtomouldthesecondshell.
Removethestockingrominsidetheorthosis.
Grindtheorthosistrimlineandsmoothit.
IanEVAhasbeenmoulded,transerthetrimlinetotheEVAandcutotheexcesswithapairoscissors.
Beore moulding the second shell, keepan angle o 90 at the corner o the
posterior/proximal trim line becausea rounded shape would create a notchin the polypropylene o the posteriorshell which might prevent proper
unctioning o the hinged joint.
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3.6 Potrior
Repairtheupperhalotheplastermodelinecessary.
3.6.1 Moui eVa
Followtheproceduredescribedinsection2.6.1(page12).
3.6.2 Vcuum moui o poypropy o t potrior
Followtheproceduredescribedinsection2.6.2(page13).
3.6.3 Prprtio o t potrior
Drawthetrimlineonthepolypropyleneasexplainedinsection3.3(page21).
CutcareullyalongtheEVAstripinthemiddleotheanteriorshellwithanoscillatingsaw.
Removetheposteriorshellromtheplastermodel.
Removethestockingrominsidetheorthosisandcutotheexcesswithajigsaw.
Grindthetrimlineandsmoothit.
IEVAhasbeenmoulded,transerthetrimlinetotheEVAandcutotheexcesswithapairoscissors.
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3.7 Prprtio or iiti ftti
3.7.1 Prprtio o t i joit
Followtheproceduredescribedinsection2.7.1(page14).
3.7.2 Prprtio o t trp
Followtheproceduredescribedinsection2.7.2(page15)ortheproximalstrap,andsection2.7.3(page16)orthedistalstrap.
3.7.3 Prprtio o eVa
IEVAisused,glueittemporarilyinsidetheorthosis.
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3.8 Iiti ftti fii
Seesection2.8(page17).
4Itisoennecessarytofarethepolypropyleneattheposteriorpartotheheelinorderto
acilitatedonningandtoavoidpainulcontactwiththeedgeotheplastic.
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ICRC Code DescriptionUnit ofmeasure
Quantity
For negative and positive cast :
ODROSTOCOT60 Tubular stockinet, 60 cm Cm 70
According to size: MDREBANDP10 MDREBANDP12 MDREBANDP15
Plaster of Paris bandages10, 12 or 15 cm x 3 m
Piece 3
OTOOPLASPW40 Plaster of Paris powder Each As required
For EVA and plastic moulding :
If required, according tocolour: OPLAEVAFERA06 OPLAEVAFLIV06 OPLAEVAFKIN06
EVA 6 mmTerra, olive or beige colour
Each As required
None Nylon stockinet Piece 1
According to colour andthickness: OPLAPOLYCHOC04 OPLAPOLYCHOC05 OPLAPOLYLIV04 OPLAPOLYLIV05 OPLAPOLYSKIN04 OPLAPOLYSKIN05
HomopolymerTerra, olive or beige colour,4 or 5 mm thick
Each As required
For the strap:
OSBOSTRVP325 Strap, Velcro, PVC, with loop, brown, 300 mm x 25 mm Piece 1
OHDWRIVET131 Rivet, tubular, 13 mm x 12 mm Piece 2
or
OSBOVSBO24 Strap, Perlon webbing, 25 mm Cm 25
None Strap, Velcro, 25 mm Cm 20
OSBOVSBO35 Loop, 25 mm x 100 pieces Piece 1
OHDWRIVET131 Rivet, tubular, 13 mm x 12 mm Piece 2
For the hinged joint:
OHDWRIVEC032 Rivet, copper, 3 mm x 20 mm Piece 2
OHDWWASHB133 Washer, brass, 13 mm dia. x 3.1 mm thick Piece 2
lit o mucturi mtri
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MISSION
The International Committee of the Red Cross (ICRC) is an impartial, neutral andindependent organization whose exclusively humanitarian mission is to protect thelives and dignity of victims of war and internal violence and to provide them withassistance. It directs and coordinates the international relief activities conductedby the Movement in situations of conict. It also endeavours to prevent suffering
by promoting and strengthening humanitarian law and universal humanitarianprinciples. Established in 1863, the ICRC is at the origin of the International RedCross and Red Crescent Movement.
Acknowledgements:
Jean Franois GallayLeo GasserPierre GauthierFrank JoumierJacques LepetitBernard Matagne
Joel NiningerGuy NuryPeter PoetsmaHmayak Tarakhchyan
and all prosthetists-orthotists who have worked in ICRC-assisted physical rehabilitation centres.
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