Greenville Binder: Alternative to Elastic Bandage Wrapping of the Lower Limbs in Young Children with Myelodysplasia

JAMES H. LITTLE, PT, WILLIAM COOLEY, III, ANDLESLIE C. MEYER, MD


Young children with thoracolumbar level myelodysplasia are prone to develop hip abduction, flexion, and external rotation contractures of varying degree. Major contributors to these contractures are:

  1. Muscle imbalance about the hip joints
  2. Diapers
  3. Position assumed by the child for balance and function

Elastic bandages wrapped around the legs with a pillow between the knees is a customary way of controlling deformities. The lower limbs are positioned toward adduction, extension, and neutral rotation. Bandages are worn during naps and at night. The act of wrapping, however, is very difficult with an active child. Pressure relief between the legs by means of the pillow is difficult to keep in proper position. The bandage is apt to slip and bunch, which can obstruct circulation, especially in insensitive limbs. Washing and drying elastic bandage is time consuming and requires special care.

We have developed a binder that is easy to apply, does not restrict circulation, stays in place, and has an adjustable pressure-relief pad to protect bony prominences.

Materials

  1. Sweat shirt fleece: orlon acrylic, I in (40 in)
  2. Polyfoarn or similar foam rubber-like plastic, 5 cm (2 in) thick, 80 x 15 cm (32 X 6 in)
  3. 3M #76 spray adhesive*
  4. Velcro: pressure-sensitive, 2.5 cm (I in) wide, I in (40 in) long pressure-sensitive, 5 cm (2 in) wide, I in (40 in) long regular, 2.5 cm (I in) wide, 10 cm (4 in) long
  5. Lightweight plastic trash bag, I mil thick
  6. Nylon thread
  7. Standard sewing machine
  8. Tape measure
  9. Scissors

Measurements

Take all measurements with the child supine.

  1. Length: umbilicus to the sole of the foot; add 2.5 cm (I in) for turning the material
  2. Waist width: circumference at the umbilicus; add 15 cm (6 in) for waist adjustment and turning the material
  3. Ankle width: circumference at the malleoli with the malleoli 5 cm (2 in) apart; add 10 cm (4 in) for closure adjustment and turning the material
  4. Pommel length: groin to the sole of the foot
  5. Pommel height: vertical distance from the measuring surface to the top of the patella

Binder Construction

Use pressure-sensitive Velcro tape for all closures, except for the pommel closure tab. Sew all Velcro for maximum security. Allow 11/2 cm (5/8 in) for all seam allowances.

Double the sweat shirt fleece, wrong side out, and draw the waist measurement on the fold. Draw the binder length perpendicular to the fold, and the ankle measurement centered under the waist measurement. Connect the lilies to form a trapezoid and cut along the lines. Sew along the lines, leaving 10- 13 cm (4-5 in) unsewn for turning the material. Trim the binder right side out and finish sewing.

Cut one strip of wide loop Velcro to equal three-fifths of the length of the right margin of the binder, minus .5 cm (1/4 in). Cut a second strip of wide loop Velcro to equal two-fifths of the length of the right binder margin, minus 3 cm (11/4 in). Sew the longer strip onto the binder front from a point .5 cm (1/4 in) from the bottom of the binder. Leave a 2.5 cm (I in) space for material flexibility at the closure. Sew the shorter strip from the top of this space to a point .5 cm (1/4 in) from the top of the binder. Cut the narrow loop Velcro to the pommel length measurement and sew it to the midline of the binder, beginning at a point .5 (1/4 in) from the bottom of the binder (Fig. 1 ).

Turn the binder over. Apply the wide hook Velcro to the right side, leaving 2.5 cm (I in) space to correspond with the loop Velcro placement. The hook Velcro should be on the side opposite to that of the loop Velcro so the binder can be closed securely. Angle the last 13 cm (5 in) of the hook Velcro 35 degrees toward the center of the binder. Apply a 13 cm (5 in) strip of narrow hook Velcro parallel to the angled piece for waist adjustment. For infants, each angled piece need be only 7.5 cm (3 in) long (Fig. 2 ).

Pommel Construction

Cut the Polyfoam to size; the length equals the groin-to-sole measurement and the height corresponds to the table- surface-to-patellar-top measurement.

Double the fleece, wrong side out. Draw the pommel cover pattern. Its length equals the groin-to-sole measurement plus the table- surface-to-patellar-top measurement; add 3 cm (11/4 in) for seam allowances. The width of the cover equals twice the table-surface-topatellar-top measurement plus 5 cm (2 in) Polyfoam width; add 3 cm (11/4 in) for seam allowances. Cut out 2.5 cm (I in) hook Velcro to the pommel length measurement. On the pommel cover, right side up, center the Velcro on the lower half of the material and sew the tape in place. Cut 10 cm (4 in) of regular (not pressure-sensitive) narrow loop Velcro for the pommel cover closure tab. Center the tab on the upper half of the wrong side of the fleece. Allowing a 7.5 cm (3 in) overhang, sew the tab onto the cover. Sew the cover and turn it right side out.

To waterproof the pommel, cut the plastic trash bag to size, allowing enough plastic to double wrap the Polyfoam and enough to package wrap the ends of the plastic. Spray only the trash bag with adhesive. Double wrap the Polyfoam, then package wrap the ends, gluing each end fold.

Place the plastic-wrapped pommel in its fleece cover. Cut the regular narrow hook Velcro to equal the pommel width, and sew the strip in place. Tuck in the dog ears and close the tab. Attach the pommel to the binder.

Fitting

Place the child on the binder and adjust the pommel placement. Hold the patient's legs in neutral rotation. Close the binder from the bottom up. Adjust the waist to the desired snugness.

Discussion

The binder consumes approximately an hour of fabrication time, from measurement through fitting. Materials cost approximately $8.00. Each child is given two binders to allow for washing. Depending on the patient's age and growth rate, binders will fit from 3 months to a year, after which they are replaced with larger ones. We have fitted children from 4 months to 5 years of age.

Over the past two years, 43 children have received binders. Parents report that the binders are easy to apply and do not compromise circulation. They remain well positioned on the child and do not irritate bony prominences. They launder well.

The Greenville Binder has proved successful in reducing hip contractures enough to allow parapodiurn fitting.

*3M, 223-6NE, 3M Center, Saint Paul, MN 55144

Mr. Little is Chief, Rehabilitation Services; Mr. Cooley is a seating technician; Dr. Meyer is Chief of Staff, Shriners Hospitals for Crippled Children, Greenville Unit, 2100 North Pleasantburg Drive, Greenville, SC 29609-3194