Physical Rehabilitation Programme

ankle-Foot orthosis
Manufacturing guidelines
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MISSION
The International Committee of the Red Cross (ICRC) is an impartial, neutral and
independent organization whose exclusively humanitarian mission is to protect the
lives and dignity of victims of war and internal violence and to provide them with
assistance. It directs and coordinates the international relief activities conducted
by the Movement in situations of confict. It also endeavours to prevent suffering
by promoting and strengthening humanitarian law and universal humanitarian
principles. Established in 1863, the ICRC is at the origin of the International Red
Cross and Red Crescent Movement.
Acknowledgements:
Jean Franois Gallay
Leo Gasser
Pierre Gauthier
Frank Joumier
Jacques Lepetit
Bernard Matagne
Joel Nininger
Guy Nury
Peter Poestma
Hmayak Tarakhchyan

and all prosthetists-orthotists who have worked in ICRC-assisted physical rehabilitation centres.
International Committee of the Red Cross
19 Avenue de la Paix
1202 Geneva, Switzerland
T + 41 22 734 60 01 F + 41 22 733 20 57
E-mail: icrc.gva@icrc.org
www.icrc.org
ICRC, September 2006
All photographs: ICRC/PRP
1 Manuf actur i ng Gui del i nes Ankl e-Foot Or thosi s
Table of contents
Foreword 2
Introduction 4
Choosingbetweendiferentdesigns 4
Castingandrectifcation 5
1.FlexibleAFO 6
1.1MouldingofEVA 6
1.2Orthosistrimline 6
1.3Vacuummouldingofthepolypropylene 6
1.4Preparationofthepolypropyleneshell 7
1.5Preparationofthestraps 8
1.6Initialfttingandfnishing 8
2.RigidAFO 8
2.1MouldingofEVA 8
2.2Orthosistrimline 9
2.3Plasticreinforcement 12
2.4Vacuummouldingofthepolypropylene 13
2.5Preparationofthepolypropyleneshell 14
2.6Proximalstrap 14
2.7Distalstrap 15
2.8Instepstrap 16
2.9Initialfttingandfnishing 18
3.AFOwithTamarackFlexureJoint
TM
18
3.1MouldingofEVA 18
3.2Orthosistrimline 18
3.3Plasticreinforcement 18
3.4InstallationofTamarackFlexureJoint
TM
19
3.5Vacuummouldingofthepolypropylene 19
3.6Preparationofthepolypropyleneshell 20
3.7Preparationofthestraps 22
3.8Initialfttingandfnishing 22
4.AFOanti-talus(anteriorshell) 22
4.1MouldingofEVA 22
4.2Orthosistrimline 23
4.3Plasticreinforcement 24
4.4Vacuummouldingofthepolypropylene 24
4.5Preparationofthepolypropyleneshell 25
4.6Preparationofthestraps 26
4.7Initialftting 26
4.8Finishing 26
Listofmanufacturingmaterials 27
2 I CRC Physi cal Rehabi l i tati on Programme
Foreword
The ICRC polypropylene technology
Sinceitsinceptionin1979,theICRCsPhysicalRehabilitationProgrammehaspromotedtheuse
oftechnologythatisappropriatetothespecifccontextsinwhichtheorganizationoperates,
i.e.,countriesafectedbywarandlow-incomeordevelopingcountries.
Tetechnologymustalsobetailoredtomeettheneedsofthephysicallydisabledinthecountries
concerned.
Tetechnologyadoptedmustthereforebe:
durable,comfortable,easyforpatientstouseandmaintain;
easyfortechnicianstolearn,useandrepair;
standardizedbutcompatiblewiththeclimateindiferentregionsoftheworld;
low-costbutmodernandconsistentwithinternationallyacceptedstandards;
easilyavailable.
Techoiceoftechnologyisofgreatimportanceforpromotingsustainablephysicalrehabilitation
services.
Forallthesereasons,theICRCpreferredtodevelopitsowntechniqueinsteadofbuyingready-made
orthopaediccomponents,whicharegenerallytooexpensiveandunsuitedtothecontextsinwhich
theorganizationworks.TecostofthematerialsusedinICRCprostheticandorthoticdevices
islowerthanthatofthematerialsusedinappliancesassembledfromcommercialready-made
components.
WhentheICRClauncheditsphysicalrehabilitationprogrammesbackin1979,locallyavailable
materialssuchaswood,leatherandmetalwereused,andorthopaediccomponentswere
manufacturedlocally.Intheearly1990stheICRCstartedtheprocessofstandardizingthe
techniquesusedinitsvariousprojectsaroundtheworld,forthesakeofharmonizationbetweenthe
projects,butmoreimportantlytoimprovethequalityofservicestopatients.
Polypropylene(PP)wasintroducedintoICRCprojectsin1988forthemanufactureofprosthetic
sockets.Tefrstpolypropyleneknee-jointwasproducedinCambodiain1991;othercomponents
suchasvariousalignmentsystemswerefrstdevelopedinColombiaandgraduallyimproved.In
parallel,adurablefoot,madeinitiallyofpolypropyleneandEthylVinylAcetate(EVA),andnowof
polypropyleneandpolyurethane,replacedthetraditionalwooden/rubberfoot.
In1998,afercarefulconsideration,itwasdecidedtoscaledownlocalcomponentproductionin
ordertofocusonpatientcareandtrainingofpersonnelatcountrylevel.
3 Manuf actur i ng Gui del i nes Ankl e-Foot Or thosi s
Objective of the manuals
TeICRCsManufacturingGuidelinesaredesignedtoprovidetheinformationnecessaryfor
productionofhigh-qualityassistivedevices.
Temainaimsoftheseinformativemanualsareasfollows:
TopromoteandenhancestandardizationofICRCpolypropylenetechnology;
Toprovidesupportfortrainingintheuseofthistechnology;
Topromotegoodpractice.
Tisisanotherstepforwardintheeforttoensurethatpatientshaveaccesstohigh-qualityservices.
ICRC
AssistanceDivision/HealthUnit
PhysicalRehabilitationProgramme
4 I CRC Physi cal Rehabi l i tati on Programme
Choosing between diferent designs
Withoutgoingintodetails,somefeaturesofdiferenttypesofAFOaresetoutbelowtoassistinthe
choiceofdesign.
Flexible AFO
Dorsifexionassistance
Poormedio-lateralstabilizationofthesubtalarjoint
Rigid AFO
Blocksanklemovements
Mediolateralstabilizationofthesubtalarjoint
Possibilityofcontrollingforefootadduction/abduction
AFO with Tamarack Flexure Joint
TM
Mediolateralstabilizationofthesubtalarjoint
Freeankledorsifexion
Freeorrestrictedankleplantarfexion
AFO anti-talus
Blocksanklemovements.Particularlyefcientforpreventingankledorsifexion
Poormediolateralstabilizationofthesubtalarjoint
Introduction
Teaimofthisdocumentistodescribeseveralmethodsformanufacturingankle-foot orthoses
(AFO),workingwiththepolypropylenetechnologyusedattheICRCsphysicalrehabilitation
centres.
5 Manuf actur i ng Gui del i nes Ankl e-Foot Or thosi s
Casting and rectifcation
Patientassessment,castingandrectifcationofpositivecastimpressionsareperformedin
accordancewithprostheticandorthotic(P&O)standards.
ForfexibleAFO,thecastcanbetakenwith5degreesofdorsifexionsoastoprovideapreloadand
ensuresomespringaction.
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1.1 Moulding of EVA
AfexibleAFOdoesnotusuallyrequireanyEVA.However,incaseswhereitisnecessarythe
proceduredescribedinsection2.1(page8)shouldbefollowed.
1.2 Orthosis trim line
Toachievethegoalofallowingdorsifexionoftheanklewhilepreventingpassiveplantarfexion,
thereareanumberofdesignoptions.
FlExIblE AFO 1
4Markthetrimlineasfollows:
A Tetopishorizontal,2cmbelowthe
fbulahead.
Attheankle,pass2cmbehindthetip
ofthemalleolitoallowfexionofthe
polypropylene.
C Attheforefoot,leavethesidesofthe
toesandtheheadofthemetatarsus
completelyclearandpassthetrim
linebelowthem.Tis will allow the
polypropylene to follow the movement of
the metatarso-phalangeal joints.
Pullastockingovertheplastermodel.
1.3 Vacuum moulding of the polypropylene
Dustthestockingwithtalcumpowder.
Measurementofthepolypropylenesheet:
1 Calfcircumference+10cm.
2 Instepcircumference+10cm.
3 Legandfootlength+10cm.(Seenextpicture.)
Tickness3mm,4mmor5mm,dependingonthepatientsweight.
7
2
1
3
Manuf actur i ng Gui del i nes Ankl e-Foot Or thosi s
Heatthepolypropyleneat180for20to25minutes,dependingonthethicknessofthe
polypropyleneandtheefciencyoftheoven.
Drapethepolypropyleneovertheplastermodelandstickittogetheralongtheanteriorside.
Tightenthepolypropylenearoundthesuctionconebymeansofaropeorsomethingsimilar.
Openthevacuumvalve.
4CutoftheexcessPPwithapairof
scissorswhileitisstillhot.
Keepthevacuumonuntilthepolypropylenecoolsdown.
1.4 Preparation of the polypropylene shell
Drawthetrimlineonthepolypropyleneasdescribedinsection1.2(page6).
Followingtheoutline,cuttheorthosiswithanoscillatingsaw.
Removetheplasticshellfromtheplastermodel.
RemovethestockingfrominsidetheAFO.
Grindtheorthosistrimlineandsmoothit.
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IfanEVAhasbeenmoulded,transferthetrimlinetotheEVAandcutoftheexcesswithapairof
scissors.
1.5 Preparation of the straps
Fortheproximalstrap,followtheproceduredescribedinsection2.6(page14).
Adistalstrapmightbeneeded,dependingonthecapacityofthepatientsshoetoholdthefoot
insidetheorthosis.Ifthisisneeded,followtheproceduredescribedinsection2.7(page15).
1.6 Initial ftting and fnishing
IfEVAisused,glueitpartiallyinsidetheorthosis.
TeinitialfttingisperformedaccordingtoP&Ostandards.
Carryouttherequiredmodifcationonthepolypropyleneandsmooththetrimline.
GluetheEVAcompletelyinsidethepolypropylene,cutofthesurplusandsmooththetrimline.
RIgId AFO 2
2.1 Moulding of EVA
EVA(6mm)maybemouldedpriortothedrapingofthepolypropylene,forthefollowingreasons:
toimprovecomfort;
topreventskinbreakageinpatientswithsensationloss;
fororthosesusedatnight.
Followtheproceduredescribedbelowor,ifthecasedoesnotrequireEVA,goontothenextsection.
9 Manuf actur i ng Gui del i nes Ankl e-Foot Or thosi s
4Positiontheplastermodelwiththe
forefootpointingdownwards.
MeasurementoftheEVAsheet:
width,instepcircumference;
length,thatoftheplastermodel
(leg+foot);
thickness,6mm.
HeattheEVAat120for3to5minutes,
dependingontheefciencyoftheoven.
DrapetheEVAmanuallyovertheplaster
modelandholditinplaceuntilithas
cooledcompletely.
4Cutoftheexcesswithacutterorapairof
scissors.
StapletheEVAontothefrontoftheplaster
model.
2.2 Orthosis trim line
2.2.1 Standard trim line
4Markthetrimlineasfollows:
A Tetopmustbehorizontal,2cmbelow
thefbulahead.
Attheankle,passtheline1cmanterior
tothetipofthemalleoli.
C Attheforefoot,leavethesidesofthe
toesandtheheadofthemetatarsus
completelyclearandpassthetrim
linebelowthem.Tis will allow the
polypropylene to follow the movement of
the metatarso-phalangeal joints.
10 I CRC Physi cal Rehabi l i tati on Programme
2.2.2 Trim line to correct forefoot adduction
Forefootadductioniscommonincasesofclubfoot.
4Markthetrimlineasfollows:
A Tetopmustbehorizontal,2cmbelow
thefbulahead.
Increasecoverageofthelateralmid-
foot,passinginfrontofthecuboid,
to enlarge the area of pressure.
C Attheforefoot,thelinemustbe
proximaltothe5thmetatarsalhead.
D Decreasecoverageofthemedial
mid-footatthenavicular/malleoli,
to facilitate donning.
Attheforefoot,coverthemedialsideof
themetatarsalheadandtoe,to correct
forefoot adduction.
11 Manuf actur i ng Gui del i nes Ankl e-Foot Or thosi s
2.2.3 Trim line to correct forefoot abduction
Forefootabductionisofenseenincasesofcerebralpalsy.
4Markthetrimlineasfollows:
A Tetopmustbehorizontal,2cmbelow
thefbulahead.
Decreasecoverageatthelevelofthe
lateralmalleoli,to ease donning.
C Attheforefoot,thelinemustbedistal
tothe5thmetatarsalhead,to avoid
metatarsus abductus.
D Increasecoverageofthemedial
mid-footatthelevelofthenavicular,
to increase mid-foot support.
Attheforefoot,thelinemustbe
proximaltothe1st

metatarsalhead.
12 I CRC Physi cal Rehabi l i tati on Programme
2.3 Plastic reinforcement
TeAFOmayneedreinforcement,especiallyatanklelevel.Ifnecessary,useoneofthefollowing
methods;otherwisegoontothenextsection.
2.3.1 double layer of polypropylene
4Asecondlayerofpolypropylene
coveringtheankleandthefootis
mouldedatthesametimeasthemain
layer.
Cutapieceofpolypropylene:
thickness,3mm;
width,instepcircumference;
length,footlength+10cm
Grindthelast3cmattheproximal
endtograduallyreducethethickness
ofthepolypropylene.
4Tetwolayersareheatedatthesame
time.
Tereinforcementisplacedonthe
plastermodel,thenthesecondlayer
isvacuum-mouldedimmediatelyto
obtainaperfectsealbetweenthetwo.
A double layer of polypropylene has the disadvantage of reducing fexibility of the forefoot in relation to
the metatarso-phalangeal joint.
13 Manuf actur i ng Gui del i nes Ankl e-Foot Or thosi s
2.3.2 Channels in the polypropylene
Tepresenceofchannelsintheplasticsignifcantlyimprovesitsstrength.Tereareseveralwaysof
makingthesechannels.
4CuttwostripsofEVA:
thickness,6mm;
width,7mm;
length,15cm.
Grindbothdistalandproximalendsto
graduallyreducethethicknessofthe
EVA.
Pullastockingovertheplastermodel.
Gluethestriplightlyontothestocking.
Te more anterior the position of the channel, the more the AFO will resist dorsifexion of the ankle.
Reinforcements prolonged along the side of the mid-foot increase the volume of the orthosis so that it
may no longer ft into the patients shoe.
2.4 Vacuum moulding of the polypropylene
Ifthishasnotyetbeendone,pullastockingovertheplastermodel.For maximum efciency, the EVA
used to make channels in the polypropylene must not be covered with a stocking.
Followtheproceduredescribedinsection1.3(page6),takingintoaccountthepresenceorabsence
ofadoublelayerofpolypropylene(section2.3.1,page12).
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2.6 Proximal strap
Useaready-madeVelcrostrap40mmwide,ormakeastrapwithPerlonwebbingorsomeother
strongmaterial.
4Withalargetubularrivet,fxthebelt
holdingthelooponthemedialside,1.5cm
belowtheproximaltrimline.
Teloopshouldbeplacedonthe
polypropyleneandnotbeincontactwiththe
patientsleg.
2.5 Preparation of the polypropylene shell
Drawthetrimlineonthepolypropyleneasdescribedinsection2.2(page9).
Cuttheorthosiswithanoscillatingsaw,followingtheoutline.
Removetheplasticshellfromtheplastermodel.
RemovethestockingfrominsidetheAFO.
Grindtheorthosistrimlineandsmoothit.
IfEVAhasbeenmouldedbeforehand,transferthetrimlinetotheEVAandcutoftheexcesswitha
pairofscissors.
15 Manuf actur i ng Gui del i nes Ankl e-Foot Or thosi s
4Insertthebeltthroughthelooptomeasure
therequiredlength.
Fixthestrapwithalargetubularrivetonthe
lateralside.Makesurethestrapisperfectly
horizontalbeforefxingit.
Coverthesurfaceofthestrapincontactwith
thepatientslegwith3mmEVA.
4Fixthestrapwithalargetubularrivetonthe
lateralside.Makesurethestrapisperfectly
horizontalbeforefxingit.
Coverthesurfaceofthestrapincontactwith
thepatientslegwith3mmEVA.
2.7 distal strap
Youmustchoosebetweenadistalstrapandaninstepstrap.Telatterhastheadvantageofholding
thecalcaneumfrmlyinsidetheorthosis(equinuscorrection).
UseaVelcrostrap25mmwide.
4Withalargetubularrivet,fxthebelt
holdingthelooponthemedialside,4cm
abovethemalleoli.
Teloopshouldbeplacedoverthe
polypropyleneandnotbeincontactwiththe
patientsleg.
16 I CRC Physi cal Rehabi l i tati on Programme
2.8 Instep strap
UseaVelcrostrap25mmwide.
Twotechniquesarepresented,dependingonwhetherthebackofthefootisinaneutralpositionor
needsavalgus/varuscorrection.
2.8.1 Neutral position
4Withalargetubularrivet,fxthebelt
holdingthelooponthemedialside,atan
angleof45passingthroughtheposterior
distaltipofthecalcaneum.
Teloopshouldbeplacedoverthe
polypropyleneandnotbeincontactwith
thepatientsleg.
4Insertthebeltthroughtheloopto
measuretherequiredlength.
Fixthestrapwithalargetubularriveton
thelateralside,atthesameangleof45.

Coverthesurfaceofthestrapincontact
withthepatientslegwith3mmEVA.
2.8.2 Varus/valgus correction
Testrapwillpassthroughaslotcutinthepolypropylene.
4Teslotiscutonthelateralsideforvarus
correctionandonthemedialsidefor
valguscorrection.
Markthepositionoftheslot40mmfrom
thebackofthefootandperpendicular
toalinedrawnatanangleof45passing
throughtheposteriordistaltipofthe
calcaneum.
Teslotshouldbe30mmlong.
17 Manuf actur i ng Gui del i nes Ankl e-Foot Or thosi s
4Makeholesalongtheslotaxiswithadrill
fttedwitha4mmbit.
4Withacutter,connecttheholeswitheach
other.
Finally,smooththetrimlinewithafle.
4Teloopisplacedonthemedialsidefor
varuscorrectionandonthelateralside
forvalguscorrection.
Fixthebeltholdingtheloopwithalarge
tubularrivet,atanangleof45passing
throughtheposteriordistaltipofthe
calcaneum.
Teloopshouldbeplacedoverthe
polypropyleneandnotbeincontactwith
thepatientsleg.
4Insertthebeltthroughtheslotonone
sideandthroughtheloopontheother
sidetomeasuretherequiredlength.
Fixthestrapwithalargetubularrivetjust
outsidetheslot.
Coverthesurfaceofthestrapincontact
withthepatientslegwith3mmEVA.
18 I CRC Physi cal Rehabi l i tati on Programme
AFO wITh TAMARACk FlExuRE JOINT
TM
3
2.9 Initial ftting and fnishing
IfEVAfoamisused,glueittemporarilyinsidetheorthosis.
TeinitialfttingisperformedinaccordancewithP&Ostandards.
Carryouttherequiredmodifcationsonthepolypropyleneandsmooththetrimline.
GluetheEVAcompletelyinsidethepolypropylene,cutofthesurplusandsmooththetrimline.
3.1 Moulding of EVA
Followtheproceduredescribedinsection2.1(page8),orgoontothenextsectionifEVAisnot
required.
3.2 Orthosis trim line
Followtheproceduredescribedinsection2.2.1(page9).
3.3 Plastic reinforcement
Posteriorreinforcementforgreaterplantarfexioncontrolisrequiredwhentheorthosisisintended
topreventplantarfexion(notfullydescribedbelow).
Followtheproceduredescribedbelow,orgoontothenextsectionifplantarfexionisleffree.
AsecondlayerofpolypropyleneforpositioningattheleveloftheAchillestendonismouldedatthe
sametimeasthemainlayer.
4Cutapieceofpolypropylene:
thickness,5mm;
width,2cm;
length,7cm.
19 Manuf actur i ng Gui del i nes Ankl e-Foot Or thosi s
4Firstthereinforcement(heatedat
thesametimeasthepolypropylene)
isplacedontheplastermodel,then
thesecondlayerisvacuum-moulded
immediatelytoobtainaperfectseal
betweenthetwolayers.
4Usethemouldingdummiestoforma
snuglyfttingcavityfortheTamarack
FlexureJoint
TM
.
Nailthemverticallyontotheplaster
modelsothatthemidpointislocated
ontheankleaxis.
3.4 Installation of Tamarack Flexure Joint
TM
Ontheplastermodel,markthepositionofthejointaxis:
laterally,attheapexofthemalleoli;
medially,slightlyposteriortothedistaltipofthemalleoli.
Makesurethatthejointsareatthesamelevelonbothsides.
3.5 Vacuum moulding of the polypropylene
Followtheproceduredescribedinsection1.3(page6),takingintoaccountthepresenceorabsence
ofaposteriorreinforcement(section3.3,page18).
Pullastocking(cottonstockinetistoothick)overtheplastermodel.
20 I CRC Physi cal Rehabi l i tati on Programme
3.6 Preparation of the polypropylene shell
Drawthetrimlineonthepolypropyleneasexplainedinsection3.2(page18).
Cutonlythecontouroftheorthosiswithanoscillatingsaw.Donotcutalongtheseparationbetween
footsectionandcalfsection.
Removetheplasticshellfromtheplastermodel.
ExtractthemouldingdummiesandthestockingfrominsidetheAFO.
4Drawtheseparationlinebetweenthefoot
sectionandthecalfsection:
Markthemiddleofthecavitiescreated
bythedummies.
DrawaVanteriortothemidlineof
eachcavity.EnsurethattheVdoesnot
extendbackwardspastthecentreofthe
cavity.
4ForAFOwith plantar fexion control,
drawahorizontallineposteriortothe
marksjoiningthetwosides.
4ForAFOwith free plantar fexion,draw
aVposteriortothemidlineofeach
cavity.EnsurethattheVdoesnot
extendforwardpastthecentreofthe
cavity.
Correct Incorrect
21 Manuf actur i ng Gui del i nes Ankl e-Foot Or thosi s
4Drillholesatthedimpleslefbytheholes
inthemouldingdummies:
5mmforlargesize;
4.5mmforsmallsize.
4Useathin-bladedsaw(1/16bladekerfor
less)toseparatethefootsectionfromthe
calfsection.
Do not use an oscillating saw because too
much material is lost along a ragged, wide
cut line.
Smooththetrimlineedgewithahanddeburringtoolorapieceofglass.Do not grind the trim line
because this will reduce fexure coverage and reduce the ability of the cavity to anchor and control the
fexure efectively.
4InserttheTamarackFlexureJoint
TM
and
securewithmetalfastenersandanchoring
screws.
Dependingonthethicknessofthe
polypropylene,itmaybenecessaryto
adjustthelengthofthescrewsiftheends
protrudeinsidetheAFO.
22 I CRC Physi cal Rehabi l i tati on Programme
3.7 Preparation of the straps
Fortheproximalstrap,followtheproceduredescribedinsection2.6(page14).
Insomecasesthepatientmightneedadistalstrap.Ifso,followtheproceduredescribedinsection
2.7(page15).
3.8 Initial ftting and fnishing
IfEVAfoamisused,glueittemporarilyinsidetheorthosis.
TeinitialfttingisperformedinaccordancewithP&Ostandards.
Carryouttherequiredmodifcationsonthepolypropyleneandsmooththetrimline.
GluetheEVAcompletelyinsidethepolypropylene,cutoftheexcessandsmooththetrimline.
Gluethefexureanchoringscrewswitharemovablethread-lockingcompound(Loctite).
AFO ANTI-TAluS (ANTERIOR ShEll) 4
4.1 Moulding of EVA
EVA(6mm)maybemouldedpriortodrapingofthepolypropylene:
toimprovecomfort;
topreventskinbreakageforpatientswithsensationloss.
Do not cover the foot, to avoid an increase of volume which may prevent the patient from wearing
normal shoes.
Followtheproceduredescribedbelow,orgoontothenextsectionifthecasedoesnotrequireEVA.
Positiontheplastermodelwiththeforefootpointingupwards.
4CutapieceofEVA:
width,calfcircumference;
length,leglength;
thickness,6mm.
HeattheEVAat120for3to
5minutes,dependingonthe
efciencyoftheoven.
DrapetheEVAovertheplaster
modelmanuallyandholditinplace
untilithascooledcompletely.
23 Manuf actur i ng Gui del i nes Ankl e-Foot Or thosi s
4Cutoftheexcesswithacutterora
pairofscissors.
Grindthedistaltrimlineto
graduallyreduceitsthickness.
StapletheEVAontothebackofthe
plastermodel.
4Marktheorthosistrimlineasfollows:
A Tetopmustbehorizontal,2cmbelow
thetibialtubercle.
Ontheleg,1cmposteriortothe
mid-line.
C Ontheankle,atthetopofthemalleoli
tofacilitatedonning.
D Ontheforefoot,clearthesidesand
topofthetoesandtheheadofthe
metatarsuscompletely,passingbelow
them.Tis will allow the polypropylene
to follow the movement of the metatarso-
phalangeal joints.
4.2 Orthosis trim line
24
2
1
3
I CRC Physi cal Rehabi l i tati on Programme
4.3 Plastic reinforcement
Tepresenceofchannelsintheplasticsignifcantlyimprovesitsstrength.Tereareseveralwaysof
makingthesechannels.
4CuttwostripsofEVA:
thickness,6mm;
width,10mm;
length,20cm.
Grindbothdistalandproximalendstogradually
reducetheirthickness.
Gluethestripsontotheplastermodel,1cmanterior
tothelateralandmediallongitudinalaxes.
Reinforcements prolonged along the side of the
mid-foot increase the volume of the orthosis so that it
may no longer ft into the patients shoe.
4.4 Vacuum moulding of the polypropylene
Te procedure described below ensures uniform thickness of the polypropylene all over the orthosis. Do
not try to make a single seam on the anterior side, because the creases gathering at the ankle will make
it necessary to stretch the polypropylene too thinly.
Ifthishasnotyetbeendone,pullastockingovertheplastermodel.For maximum efciency the EVA
used to channel the polypropylene must not be covered with a stocking.
Dustthestockingwithtalcumpowder.
Measurementofthepolypropylenesheet:
1 Calfcircumference+10cm.
2 Instepcircumference+10cm.
3 Legandfootlength+10cm.
PPthickness:4mmor5mm,dependingonthepatientsweight.
25 Manuf actur i ng Gui del i nes Ankl e-Foot Or thosi s
Heatthepolypropyleneat180for20to25minutes,dependingonthethicknessofthe
polypropyleneandtheefciencyoftheoven.
Drapethepolypropyleneovertheplastermodelandstickittogetheralongtheposteriorsideand
underthefoot.
Tightenthepolypropylenearoundthesuctionconewitharopeorsomethingsimilar.
Openthevacuumvalve.
4Cutoftheexcesswithapairofscissors
whilethepolypropyleneisstillhot.
Keepthevacuumonuntilthepolypropylenecoolsdown.
4.5 Preparation of the polypropylene shell
Drawthetrimlineonthepolypropyleneasexplainedinsection4.2(page23).
Cuttheorthosiswithanoscillatingsaw,followingtheoutline.
Removetheplasticshellfromtheplastermodel.
RemovethestockingfrominsidetheAFO.
Grindtheorthosistrimlineandsmoothit.
IfEVAhasbeenmouldedbeforehand,transferthetrimlinetotheEVAandcutoftheexcesswitha
pairofscissors.
26 I CRC Physi cal Rehabi l i tati on Programme
4.7 Initial ftting
IfEVAfoamisused,glueittemporarilyinsidetheorthosis.
TeinitialfttingisperformedinaccordancewithP&Ostandards.
4Itisofennecessarytofarethepolypropylene
attheposteriorpartoftheheelinorderto
facilitatedonningandtoavoidpainfulcontact
withtheedgeoftheplastic.
4.6 Preparation of the straps
Fortheproximalstrap,followtheprocedure
describedinsection2.6(page14).
Insomecasesthepatientmightneedadistalstrap.
Ifso,followtheproceduredescribedinsection2.7
(page15).
4.8 Finishing
Carryouttherequiredmodifcationsonthepolypropyleneandsmooththetrimline.
GluetheEVAinsidethepolypropylene,cutofthesurplusandsmooththetrimline.
27 Manuf actur i ng Gui del i nes Ankl e-Foot Or thosi s
ICRC Code Description
Unit of
measure
Quantity
For negative and positive cast :
ODROSTOCOT60 Tubular stockinet, 60 cm cm 70
According to size:
MDREBANDP10
MDREBANDP12
MDREBANDP15
Plaster of Paris bandages
10, 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 to
colour:
OPLAEVAFERA06
OPLAEVAFLIV06
OPLAEVAFKIN06
EVA 6 mm
Terra, olive or beige colour
Each As required
None Nylon stockinet Piece 1
According to colour and
thickness:
OPLAPOLYCHOC03
OPLAPOLYCHOC04
OPLAPOLYCHOC05
OPLAPOLYLIV03
OPLAPOLYLIV04
OPLAPOLYLIV05
OPLAPOLYSKIN03
OPLAPOLYSKIN04
OPLAPOLYSKIN05
Homopolymer
Terra, olive or beige colour
3, 4 or 5 mm thickness
Each As required
For the TAMARACK Flexure Joint
TM
:
According to size:
OCPOSOOTTAL
OCPOSOOTTAS
Large size (740L)
Small size (740S)
Piece 1
EHDWGLUEL243 Glue, Loctite 243, blue, threadlock, 50-ml bottle As required 4
For the proximal strap:
OSBOSTRVP440 Strap, Velcro, PVC, with loop, brown, 400 x 40 mm Piece 1
OHDWRIVET131 Rivet, tubular, 13 mm x 12 mm Piece 2
or
OSBOVSBO30 Strap, polyester, black, 40 mm cm 25
None Strap, Velcro, 40 mm cm 20
None Loop, 40 mm x 100 pieces Piece 1
OHDWRIVET131 Rivet, tubular, 13 mm x 12 mm Piece 2
For distal/instep 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 20
None Strap, Velcro, 25 mm cm 15
OSBOVSBO35 Loop, 25 mm x 100 pieces Piece 1
OHDWRIVET131 Rivet, tubular, 13 mm x 12 mm Piece 2
list of manufacturing materials
MISSION
The International Committee of the Red Cross (ICRC) is an impartial, neutral and
independent organization whose exclusively humanitarian mission is to protect the
lives and dignity of victims of war and internal violence and to provide them with
assistance. It directs and coordinates the international relief activities conducted
by the Movement in situations of confict. It also endeavours to prevent suffering
by promoting and strengthening humanitarian law and universal humanitarian
principles. Established in 1863, the ICRC is at the origin of the International Red
Cross and Red Crescent Movement.
Acknowledgements:
Jean Franois Gallay
Leo Gasser
Pierre Gauthier
Frank Joumier
Jacques Lepetit
Bernard Matagne
Joel Nininger
Guy Nury
Peter Poetsma
Hmayak Tarakhchyan

and all prosthetists-orthotists who have worked in ICRC-assisted physical rehabilitation centres.
International Committee of the Red Cross
19 Avenue de la Paix
1202 Geneva, Switzerland
T + 41 22 734 60 01 F + 41 22 733 20 57
E-mail: icrc.gva@icrc.org
www.icrc.org
ICRC, September 2006
All photographs: ICRC/PRP
Physical Rehabilitation Programme
ankle-Foot orthosis
Manufacturing guidelines
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Physical Rehabilitation Programme
Patellar
tendon-bearing orthosis
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2
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Manufacturing guidelines
MISSION
The International Committee of the Red Cross (ICRC) is an impartial, neutral and
independent organization whose exclusively humanitarian mission is to protect the
lives and dignity of victims of war and internal violence and to provide them with
assistance. It directs and coordinates the international relief activities conducted
by the Movement in situations of confict. It also endeavours to prevent suffering
by promoting and strengthening humanitarian law and universal humanitarian
principles. Established in 1863, the ICRC is at the origin of the International Red
Cross and Red Crescent Movement.
Acknowledgements:
Jean Franois Gallay
Leo Gasser
Pierre Gauthier
Frank Joumier
Jacques Lepetit
Bernard Matagne
Joel Nininger
Guy Nury
Peter Poestma
Hmayak Tarakhchyan

and all prosthetists-orthotists who have worked in ICRC-assisted physical rehabilitation centres.
International Committee of the Red Cross
19 Avenue de la Paix
1202 Geneva, Switzerland
T + 41 22 734 60 01 F + 41 22 733 20 57
E-mail: icrc.gva@icrc.org
www.icrc.org
ICRC, September 2006
All photographs: ICRC/PRP
1 Manuf actur i ng Gui del i nes Patel l ar Tendon-Bear i ng Or thosi s
Table of contents
Foreword 2
Introduction 4
Choosingbetweentwomethods 4
1.Castingandrectifcation 5
2.PTBOwithanterior-closingshell 6
2.1EVApreparationforincreasedweightrelief 6
2.2MouldingofEVA 7
2.3Orthosistrimline 8
2.4Plasticreinforcement 9
2.5Posteriorshell 10
2.6.Anteriorshell 12
2.7Preparationforinitialftting 14
2.8Initialfttingandfnishing 17
3.PTBOwithposterior-closingshell 19
3.1EVApreparationforincreasedweightrelief 19
3.2MouldingofEVA 20
3.3Orthosistrimline 21
3.4Plasticreinforcement 22
3.5Anteriorshell 22
3.6Posteriorshell 25
3.7Preparationforinitialftting 26
3.8Initialfttingandfnishing 27
Listofmanufacturingmaterials 28
2 I CRC Physi cal Rehabi l i tati on Programme
Foreword
The ICRC polypropylene technology
Sinceitsinceptionin1979,theICRCsPhysicalRehabilitationProgrammehaspromotedtheuse
oftechnologythatisappropriatetothespecifccontextsinwhichtheorganizationoperates,
i.e.,countriesafectedbywarandlow-incomeordevelopingcountries.
Tetechnologymustalsobetailoredtomeettheneedsofthephysicallydisabledinthecountries
concerned.
Tetechnologyadoptedmustthereforebe:
durable,comfortable,easyforpatientstouseandmaintain;
easyfortechnicianstolearn,useandrepair;
standardizedbutcompatiblewiththeclimateindiferentregionsoftheworld;
low-costbutmodernandconsistentwithinternationallyacceptedstandards;
easilyavailable.
Techoiceoftechnologyisofgreatimportanceforpromotingsustainablephysicalrehabilitation
services.
Forallthesereasons,theICRCpreferredtodevelopitsowntechniqueinsteadofbuyingready-made
orthopaediccomponents,whicharegenerallytooexpensiveandunsuitedtothecontextsinwhich
theorganizationworks.TecostofthematerialsusedinICRCprostheticandorthoticdevices
islowerthanthatofthematerialsusedinappliancesassembledfromcommercialready-made
components.
WhentheICRClauncheditsphysicalrehabilitationprogrammesbackin1979,locallyavailable
materialssuchaswood,leatherandmetalwereused,andorthopaediccomponentswere
manufacturedlocally.Intheearly1990stheICRCstartedtheprocessofstandardizingthe
techniquesusedinitsvariousprojectsaroundtheworld,forthesakeofharmonizationbetweenthe
projects,butmoreimportantlytoimprovethequalityofservicestopatients.
Polypropylene(PP)wasintroducedintoICRCprojectsin1988forthemanufactureofprosthetic
sockets.Tefrstpolypropyleneknee-jointwasproducedinCambodiain1991;othercomponents
suchasvariousalignmentsystemswerefrstdevelopedinColombiaandgraduallyimproved.In
parallel,adurablefoot,madeinitiallyofpolypropyleneandEthylVinylAcetate(EVA),andnowof
polypropyleneandpolyurethane,replacedthetraditionalwooden/rubberfoot.
In1998,afercarefulconsideration,itwasdecidedtoscaledownlocalcomponentproductionin
ordertofocusonpatientcareandtrainingofpersonnelatcountrylevel.
3 Manuf actur i ng Gui del i nes Patel l ar Tendon-Bear i ng Or thosi s
Objective of the manuals
TeICRCsManufacturingGuidelinesaredesignedtoprovidetheinformationnecessaryfor
productionofhigh-qualityassistivedevices.
Temainaimsoftheseinformativemanualsareasfollows:
TopromoteandenhancestandardizationofICRCpolypropylenetechnology;
Toprovidesupportfortrainingintheuseofthistechnology;
Topromotegoodpractice.
Tisisanotherstepforwardintheeforttoensurethatpatientshaveaccesstohigh-qualityservices.
ICRC
AssistanceDivision/HealthUnit
PhysicalRehabilitationProgramme
4 I CRC Physi cal Rehabi l i tati on Programme
Choosing between two methods
Tefollowingindicationsmighthelpinmakingachoicebetweenthetwopossiblemethods.
Weight relief: partial or complete?
Accordingtotheprescriptionand/orthepathology,theorthosismustpartiallyorcompletelyrelieve
theweightappliedontheleg.
Tothisend,alayerofEVAisaddedunderthefootpriortothedrapingofthepolypropylene.
Tefollowingfguresgivearoughestimateofthedegreeofweightrelief:
NoEVA:70%oftheweightonthelegand30%ontheorthosis.
3mmEVA:50%onthelegand50%ontheorthosis.
6mmEVA:30%onthelegand70%ontheorthosis.
12mmEVA:0%onthelegand100%ontheorthosis.
Introduction
Teaimofthisdocumentistodescribetwomethodsforproducingpatellar tendon-bearing (PTB)
orthoses,workingwiththeICRCpolypropylenetechnologyandorthopaediccomponentsusedat
theICRCsphysicalrehabilitationcentres.
Anterior-cIosing sheII Posterior-cIosing sheII
Weak at ankle level, especially for heavy
patients or patients walking with ankle
dorsifexion.
Strong at ankle level, thus suitable for
overweight patients or patients walking with
ankle dorsifexion.
Easy to ft into normal shoes.
Sometime difcult to ft into normal shoes
because of the volume of the orthosis at
mid-foot.
5 Manuf actur i ng Gui del i nes Patel l ar Tendon-Bear i ng Or thosi s
Patientassessment,castingandrectifcationofpositivecastimpressionsareperformedin
accordancewithprostheticandorthotic(P&O)standards,takingintoaccountthefollowingpoints:
Teproximalpartismanufacturedlikeatrans-tibialprosthesisandensurestheweight-bearing
function.
Tedistalpartismanufacturedlikeanankle-footorthosis.
Teremustbelittleornoweightborneonthelegwhilethecastisbeingtaken.
Inthemethodinvolvingaposterior-closingshell,theEVAusedtoincreaseweightreliefisplaced
onlyundertheheel,soitafects the position of the cast(seesection3.1,page19).
CasTIng and ReCTIFICaTIOn 1
6 I CRC Physi cal Rehabi l i tati on Programme
2.1 eVa preparation for increased weight relief
Followtheproceduredescribedbelow,orgoontothenextsectionifthepatientdoesnotrequire
additionalweightrelief.
PTBO WITh anTeRIOR-ClOsIng shell 2
4PlacetheplastermodelontheEVA
sheetanddrawalinearoundit
1cmwiderthanthefoot.
4Holdtheplastermodelinavice.
HeattheEVAat120for3to5
minutes,dependingonitsthickness
andontheefciencyoftheoven.
PuttheEVAunderthefootand
holditfrmlyinplacewithan
elasticbandageforoneminute.
GrindtheedgeoftheEVAuntilitisperfectlyalignedwiththeshapeoftheplastermodel.
7 Manuf actur i ng Gui del i nes Patel l ar Tendon-Bear i ng Or thosi s
6GluetheEVAundertheplastermodel.
2.2 Moulding of eVa
EVA(6mm)canbemouldedpriortodrapingofthepolypropylene:
toimprovecomfort;
topreventskinbreakageinpatientswithsensationloss.
Followtheproceduredescribedbelow,orgoontothenextsectionifEVAisnotrequired.
4Positiontheplastermodelwiththe
forefootpointingdownwards.
CutapieceofEVA:
width,kneecircumference;
length,thelengthoftheplaster
model(leg+foot);
thickness,6mm.
HeattheEVAat120for3to5
minutes,dependingontheefciency
oftheoven.
DrapetheEVAovertheplastermodel
manuallyandholditinplaceuntilit
hascompletelycooled.
8 I CRC Physi cal Rehabi l i tati on Programme
2.3 Orthosis trim line
4Cutoftheexcesswithacutterora
pairofscissors.
StapletheEVAontothefrontofthe
plastermodel.
4Marktheorthosistrimlineasfollows:
A Tetopmustbehorizontal,6cmabove
thepatellatendongroove.
Tepatellaandthehamstringtendons
areleffree.
C Teshelloverlapstheantero-posterior
mid-lineby1.5cm.
D Attheankle,keeptheline1cmanterior
tothetopofthemalleoli.
Teusualdistallimitoftheanterior
shellishorizontal,at1/3ofthelength
oftheleg,butmaybelongertoprovide
greaterprotection.
F Attheforefoot,clearthesidesofthe
toesandtheheadofthemetatarsus
completely,passingbeneaththem.Tis
will allow the polypropylene to follow the
movement of the metatarso-phalangeal
joints.
9 Manuf actur i ng Gui del i nes Patel l ar Tendon-Bear i ng Or thosi s
2.4 Plastic reinforcement
Teorthosismayneedreinforcement,especiallyatanklelevel.Ifthisisthecase,followoneofthe
proceduresdescribedbelow;otherwisegoontothenextsection.
2.4.1 double layer of polypropylene
4Asecondlayerofpolypropylene
coveringtheankleandthefootis
mouldedatthesametimeasthemain
layer.
Cutapieceofpolypropylene:
thickness,3mm;
width,instepcircumference;
length,lengthoffoot+10cm.
Grindthelast3cmattheproximal
endtograduallyreducethethickness
ofthepolypropylene.
4Tetwolayersareheatedatthesame
time.
Tereinforcementisplacedonthe
plastermodel,thenthesecondlayer
isvacuum-mouldedimmediately
aferwardstoobtainaperfectseal
betweenthetwolayers.
Te double layer of polypropylene has the disadvantage of reducing fexibility of the forefoot in relation
to the metatarso-phalangeal joint.
10 I CRC Physi cal Rehabi l i tati on Programme
2.4.2 lateral reinforcements (channels)
4CuttwobandsofEVA:
thickness,6mm;
width,7mm;
length,15cm.
Pullastockingovertheplastermodel.
Gluethebandlightlyontothestocking.
Te more anterior the position of the
channel, the more the device will resist
dorsifexion of the ankle.
Reinforcements prolonged along the side
of the mid-foot increase the volume of
the orthosis so that it may no longer ft
into the patients shoe.
2.5 Posterior shell
2.5.1 Vacuum moulding of polypropylene
Ifthishasnotalreadybeendone,pullastockingovertheplastermodel.For maximum efciency, the
EVA used to channel the polypropylene must not be covered with a stocking.
Dustthestockingwithtalcumpowder.
Measurementofthepolypropylenesheet:
1 Kneecircumference+10cm.
2 Instepcircumference+10cm.
3 Legandfootlength+10cm.
Tickness,4mmor5mm,dependingonthepatientsweight.
2
1
3
11 Manuf actur i ng Gui del i nes Patel l ar Tendon-Bear i ng Or thosi s
Heatthepolypropyleneat180for20to25minutes,dependingonthethicknessofthe
polypropyleneandtheefciencyoftheoven.
Drapethepolypropyleneovertheplastermodelandstickittogetheralongtheanteriorside.
Tightenthepolypropylenearoundthesuctionconewitharopeorsomethingsimilar.
Openthevacuumvalve.
4Cutoftheexcesswithapairofscissors
whilethepolypropyleneisstillhot.
2.5.2 Preparation of the posterior shell
Drawthetrimlineonthepolypropyleneasexplainedinsection2.3(page8).
Cuttheorthosiswithanoscillatingsaw,followingtheoutline.
Removetheshellgentlytoavoiddamagingtheproximalpartoftheplastermodel,asitwillbeused
tomouldthesecondshell.
Removethestockingfrominsidetheorthosis.
Grindthetrimlineandsmoothit.
IfanEVAhasbeenmoulded,transferthetrimlinetotheEVAandcutoftheexcesswithapairof
scissors.
Before moulding the second shell,
keep an angle of 90 at the corner
of the anterior/proximal trim line
because a rounded shape would
create a notch in the polypropylene
of the posterior shell which might
prevent proper functioning of the
hinged joint.
Keepthevacuumonuntilthepolypropylenecoolsdown.
12 I CRC Physi cal Rehabi l i tati on Programme
2.6 anterior shell
Repairtheproximalpartoftheplastermodelifnecessary.
2.6.1 Moulding eVa
Toimprovecomfort,6mmEVAcanbemouldedpriortodrapingofthepolypropylene,whetheror
notthesamehasbeendonefortheothershell.
Followtheproceduredescribedbelow,orgoontothenextsectionifEVAisnotrequired.
4CutapieceofEVA6mmthickand
largeenoughtocovertheproximal
halfoftheplastermodel.
HeattheEVAat120for3to
5minutes,dependingonthe
efciencyoftheoven.
PuttheEVAovertheplastermodel
andholdittightlyinplacewithan
elasticbandageforoneminute.
4RemovetheEVAandcutit,
followingthetrimline.
Takethepolypropyleneshell(with
itsEVA)andfxthenewlymoulded
EVAwithtwostaplesclosetothe
proximal/medialtrimline.
13 Manuf actur i ng Gui del i nes Patel l ar Tendon-Bear i ng Or thosi s
2.6.2 Vacuum moulding of polypropylene on the anterior shell
4GlueastripofEVA6mmthickand
3cmwidearoundthemiddleofthe
plastermodel.Te polypropylene
draping will stop at this level, where
the rope tightened around the EVA will
ensure a sufcient vacuum.
GlueanotherstripofEVA6mmthick
and3cmwideonthemiddleofthe
frstpolypropyleneshellatrightangles
tothefrststrip.Tis will allow the
polypropylene to be cut afer draping
without damaging the shell beneath.
Coverwithastockingtheareareceivingthepolypropylene.Do not cover the strip of EVA where the
rope will be tightened because the vacuum may leak through the stocking mesh.
Placetheplastermodelwiththeforefootpointingupwards.
Dustthestockingwithtalcumpowder.
Cutapieceofpolypropylene:
width,kneecircumference+5cm;
length,halftheleglength+10cm;
thickness,4mmor5mm,dependingonthepatientsweight.
Heatthepolypropyleneat180for15to20minutes,dependingonthethicknessofthe
polypropyleneandtheefciencyoftheoven.
4Drapethepolypropyleneoverthe
plastermodelandstickittogetheralong
thelongitudinalstripofEVA.
Tightenthepolypropylenearoundthe
suctioncone.
Openthevacuumvalve.
Cutoftheexcesswithapairofscissors
whilethepolypropyleneisstillhot.
Keepthevacuumonuntilthepolypropylenecoolsdown.
14 I CRC Physi cal Rehabi l i tati on Programme
2.6.3 Preparation of the anterior shell
Drawthetrimlineonthepolypropyleneasexplainedinsection2.3(page8).
CutcarefullyalongtheEVAstripinthemiddleoftheposteriorshellwithanoscillatingsaw.
Removetheposteriorshellfromtheplastermodel.
Removethestockingfrominsidetheorthosisandcutoftheexcesswithajigsaw.
Grindthetrimlineandsmoothit.
IfanEVAsheethasbeenmoulded,transferthetrimlinetotheEVAandcutoftheexcesswitha
pairofscissors.
2.7 Preparation for initial ftting
2.7.1 Preparation of the hinged joint
4Securethetwoshellsontheplaster
mouldwithScotchtape.
Markthepositionofthehinged
jointonthelateralandmedialsides:
4.5cmabovethepatellartendon
groove;
inthemiddleoftheantero-
posteriordiameter.
Makesurethatthehingedjointson
bothsidesareatthesamelevel.
15 Manuf actur i ng Gui del i nes Patel l ar Tendon-Bear i ng Or thosi s
4Drillahole3mmindiameterthrough
bothshells.
4Assembletheanteriorandposterior
shellswith2slottedscrewsandnuts
3mmindiameter(headinside).
Cutandgrindtheboltprotruding
fromthenut.
2.7.2 Proximal strap
Useaready-madeVelcrostrap25mmwide,ormakeastrapwithnylonwebbingorsomeother
strongmaterial.
4Withatubularrivet,fxthebelt
holdingthelooponthemedialsideof
theposteriorshell,atthedistallimitof
theanteriorshell.
Teloopshouldbelocated5mmfrom
theanteriorshell.
16 I CRC Physi cal Rehabi l i tati on Programme
4Insertthebeltthroughthelooptomeasure
thelength.
Fixthestrapwithatubularrivetonthe
lateralside.
Makesurethestrapisperfectlyhorizontal
beforefxingit.
2.7.3 distal strap
Tisstrapisnotalwaysneeded.Tedecisiontoinstallitorotherwisewilldependonthecapacityof
thepatientsshoetoholdthefootinsidetheorthosis.
Usea25mmVelcrostrap.
4Withalargetubularrivet,fxthebelt
holdingthelooponthemedialside,4cm
abovethemalleoli.
Teloopshouldbeplacedonthe
polypropyleneandnotbeincontactwiththe
patientsleg.
4Fixthestrapwithalargetubularrivetonthe
lateralside.Makesurethestrapisperfectly
horizontalbeforefxingit.
Coverthesurfaceofthestrapincontactwith
thepatientslegwith3mmEVA.
2.7.4 Preparation of the eVa
IfEVAisused,glueittemporarilyinsidetheorthosis.
17 Manuf actur i ng Gui del i nes Patel l ar Tendon-Bear i ng Or thosi s
2.8 Initial ftting and fnishing
4Tepatientputsontheorthosisby
openingtheanteriorshellandsliding
his/herfootthroughtheproximalend.
TeinitialfttingisperformedinaccordancewithP&Ostandards,takingthefollowingpointsinto
account.
Shouldthepatientslegslipthroughthebrim,theproximalpartcanbepaddedwithEVAto
decreaseitswidth.
Whilethepatientisstanding,checkthedegreeofweightrelief.
Aheellifonthecontrolateralsidemightbeneededtoaccommodatetheincreaseinlengthofthe
legwiththeorthosis.
2.8.1 Finishing of the polypropylene
4Roundofthecornersofbothanterior
andposteriorshells.
Carryoutanymodifcationsrequiredonthepolypropyleneandsmooththetrimline.
GluetheEVAcompletelyinsidethepolypropylene,cutoftheexcessandsmooththetrimline.
18 I CRC Physi cal Rehabi l i tati on Programme
2.8.2 Finishing of the hinged joint
Usetwocopperrivets3mmindiameterwithtwobrassorstainlesssteelwashers.
Removethe3mmboltononesideofeachrivet.
Heatthecopperrivetwithaweldinggunandstampitsheadintothepolypropyleneoftheanterior
shellinordertocreatedepressionstocountersinktherivethead.
4Placetherivetheadonananviland
hammergentlyonthepartoftherivet
protrudingfromthewasherinorder
tocreateasmooth,roundedshapeas
shownonthepicture.Usearivetsetto
rounditof.
Inserttherivet,headinside,andinstallthewasheroutside.
Cuttherivetwithdouble-actioncuttingpliersorside-cuttingplierssothatonly2mmprotrudes
fromthewasher.
Dothesamefortheotherside.
19 Manuf actur i ng Gui del i nes Patel l ar Tendon-Bear i ng Or thosi s
PTBO WITh POsTeRIOR-ClOsIng shell 3
3.1 eVa preparation for increased weight relief
Te EVA is placed only under the posterior part of the foot, in order to avoid an increase in volume at
the mid-foot which may prevent the patient from wearing normal shoes.
Followtheproceduredescribedbelow,orgoontothenextsectionifthepatientdoesnotrequire
additionalweightrelief.
4Placethemetatarsalheadoftheplaster
modelattheedgeoftheEVAsheetand
drawalinearoundit1cmwiderthan
thefoot.
4Holdtheplastermodelinavice.
HeattheEVAat120for3to5minutes,
dependingonthethicknessoftheEVA
andtheefciencyoftheoven.
PuttheEVAundertheposteriorpartof
thefootandholditfrmlyinplacefor
oneminutewithanelasticbandage.
20 I CRC Physi cal Rehabi l i tati on Programme
GrindtheedgeoftheEVAuntilitisperfectlyaligned,aroundandbelow,withtheshapeofthe
plastermodel.
6GluetheEVAundertheplastermodel.
3.2 Moulding of eVa
EVA(6mm)canbemouldedpriortodrapingofthepolypropylenetoimprovecomfort.
Do not cover the foot, as this would create an increase of volume which might prevent the patient from
wearing normal shoes.
Followtheproceduredescribedbelow,orgoontothenextsectionifEVAisnotrequired.
Placetheplastermodelwiththeforefootpointingupwards.
4CutapieceofEVA:
width,kneecircumference;
length,leglength;
thickness,6mm.
HeattheEVAat120for3to
5minutes,dependingonthe
efciencyoftheoven.
DrapetheEVAovertheplaster
modelmanuallyandholditinplace
untilithascooledcompletely.
21 Manuf actur i ng Gui del i nes Patel l ar Tendon-Bear i ng Or thosi s
4Cutoftheexcesswithacutterora
pairofscissors.
Grindthedistaltrimlinetogradually
reduceitsthickness.
StapletheEVAontothebackofthe
plastermodel.
3.3 Orthosis trim line
4Markthetrimlineasfollows:
A Tetopmustbehorizontal,6cmabove
thepatellatendongroove.
Tepatellaandthehamstringtendons
areleffree.
C Teshelloverlapstheantero-posterior
mid-lineby1.5cm.
D Attheankle,thelinemustremain
abovethemalleolitofacilitatedonning.
Teusualdistallimitoftheposterior
shellishorizontal,at1/3ofthelength
oftheleg,butitmaybelongerto
providegreaterprotection.
F Attheforefoot,clearthesideandthe
topofthetoesandtheheadofthe
metatarsuscompletely,passingbeneath
them.Tis will allow the polypropylene
to follow the movement
of the metatarso-phalangeal joints.
22 I CRC Physi cal Rehabi l i tati on Programme
3.4 Plastic reinforcement
Lateralreinforcements(channels)signifcantlyimprovethestrengthoftheorthosis.Tereare
severalwaysofmakingthesereinforcements.
4CuttwostripsofEVA:
width10mm;
length20cm;
thickness,6mm.
Grindbothdistalandproximalendsto
graduallyreducetheirthickness.
Gluethestripsontotheplastermodel,
1cmanteriortothelateralandmedial
longitudinalaxis.
Reinforcements prolonged along the side
of the mid-foot increase the volume of the
orthosis so that it may no longer ft into the
patients shoe.
3. 5 anterior shell
3.5.1 Vacuum moulding of polypropylene
Te procedure described below ensures uniform thickness of the polypropylene all over the orthosis. Do
not try to make a single seam on the anterior side, because the creases gathering at ankle level will make
it necessary to stretch the polypropylene too thinly.
Ifthishasnotyetbeendone,pullastockingovertheplastermodel.For maximum efciency the EVA
used to channel the polypropylene must not be covered with a stocking.
Dustthestockingwithtalcumpowder.
23
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Manuf actur i ng Gui del i nes Patel l ar Tendon-Bear i ng Or thosi s
Measurementofthepolypropylenesheet:
1 Kneecircumference+10cm.
2 Instepcircumference+10cm.
3 Legandfootlength+10cm.
Tickness,4mmor5mm,dependingonthepatientsweight.
Heatthepolypropyleneat180for20to25minutes,dependingonthethicknessofthe
polypropyleneandtheefciencyoftheoven.
Drapethepolypropyleneovertheplastermodelandstickittogetheralongtheposteriorsideand
underthefoot.
Tightenthepolypropylenearoundthesuctioncone.
Openthevacuumvalve.
4Cutoftheexcesswithapairof
scissorswhilethepolypropyleneis
stillhot.
Keepthevacuumonuntilthepolypropylenecoolsdown.
24 I CRC Physi cal Rehabi l i tati on Programme
3.5.2 Preparation of the anterior shell
Drawthetrimlineonthepolypropyleneasexplainedinsection3.3(page21).
Cuttheorthosiswithanoscillatingsaw,followingtheoutline.

Toremovetheshell,itmightbenecessarytobreakthedistalpartoftheplastermodelbelowthe
ankle.However,caremustbetakennottodamagetheproximalpart,whichisneededtomouldthe
secondshell.
Removethestockingfrominsidetheorthosis.
Grindtheorthosistrimlineandsmoothit.
IfanEVAhasbeenmoulded,transferthetrimlinetotheEVAandcutoftheexcesswithapairof
scissors.
Before moulding the second shell, keep
an angle of 90 at the corner of the
posterior/proximal trim line because
a rounded shape would create a notch
in the polypropylene of the posterior
shell which might prevent proper
functioning of the hinged joint.
25 Manuf actur i ng Gui del i nes Patel l ar Tendon-Bear i ng Or thosi s
3.6 Posterior shell
Repairtheupperhalfoftheplastermodelifnecessary.
3.6.1 Moulding eVa
Followtheproceduredescribedinsection2.6.1(page12).
3.6.2 Vacuum moulding of polypropylene on the posterior shell
Followtheproceduredescribedinsection2.6.2(page13).
3.6.3 Preparation of the posterior shell
Drawthetrimlineonthepolypropyleneasexplainedinsection3.3(page21).
CutcarefullyalongtheEVAstripinthemiddleoftheanteriorshellwithanoscillatingsaw.
Removetheposteriorshellfromtheplastermodel.
Removethestockingfrominsidetheorthosisandcutoftheexcesswithajigsaw.
Grindthetrimlineandsmoothit.
IfEVAhasbeenmoulded,transferthetrimlinetotheEVAandcutoftheexcesswithapairofscissors.
26 I CRC Physi cal Rehabi l i tati on Programme
3.7 Preparation for initial ftting
3.7.1 Preparation of the hinged joint
Followtheproceduredescribedinsection2.7.1(page14).
3.7.2 Preparation of the straps
Followtheproceduredescribedinsection2.7.2(page15)fortheproximalstrap,andsection2.7.3
(page16)forthedistalstrap.
3.7.3 Preparation of eVa
IfEVAisused,glueittemporarilyinsidetheorthosis.
27 Manuf actur i ng Gui del i nes Patel l ar Tendon-Bear i ng Or thosi s
3.8 Initial ftting and fnishing
Seesection2.8(page17).
4Itisofennecessarytofarethepolypropylene
attheposteriorpartoftheheelinorderto
facilitatedonningandtoavoidpainfulcontact
withtheedgeoftheplastic.
28 I CRC Physi cal Rehabi l i tati on Programme
ICRC Code Description
Unit of
measure
Quantity
For negative and positive cast :
ODROSTOCOT60 Tubular stockinet, 60 cm Cm 70
According to size:
MDREBANDP10
MDREBANDP12
MDREBANDP15
Plaster of Paris bandages
10, 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 to
colour:
OPLAEVAFERA06
OPLAEVAFLIV06
OPLAEVAFKIN06
EVA 6 mm
Terra, olive or beige colour
Each As required
None Nylon stockinet Piece 1
According to colour and
thickness:
OPLAPOLYCHOC04
OPLAPOLYCHOC05
OPLAPOLYLIV04
OPLAPOLYLIV05
OPLAPOLYSKIN04
OPLAPOLYSKIN05
Homopolymer
Terra, 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
list of manufacturing materials
MISSION
The International Committee of the Red Cross (ICRC) is an impartial, neutral and
independent organization whose exclusively humanitarian mission is to protect the
lives and dignity of victims of war and internal violence and to provide them with
assistance. It directs and coordinates the international relief activities conducted
by the Movement in situations of confict. It also endeavours to prevent suffering
by promoting and strengthening humanitarian law and universal humanitarian
principles. Established in 1863, the ICRC is at the origin of the International Red
Cross and Red Crescent Movement.
Acknowledgements:
Jean Franois Gallay
Leo Gasser
Pierre Gauthier
Frank Joumier
Jacques Lepetit
Bernard Matagne
Joel Nininger
Guy Nury
Peter Poetsma
Hmayak Tarakhchyan

and all prosthetists-orthotists who have worked in ICRC-assisted physical rehabilitation centres.
International Committee of the Red Cross
19 Avenue de la Paix
1202 Geneva, Switzerland
T + 41 22 734 60 01 F + 41 22 733 20 57
E-mail: icrc.gva@icrc.org
www.icrc.org
ICRC, September 2006
All photographs: ICRC/PRP
Physical Rehabilitation Programme
ankle-Foot orthosis
Manufacturing guidelines
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Manufacturing guidelines
International Committee of the Red Cross
19 Avenue de la Paix
1202 Geneva, Switzerland
T + 41 22 734 60 01 F + 41 22 733 20 57
E-mail: icrc.gva@icrc.org
www.icrc.org
ICRC, September 2006
All photographs: ICRC/PRP
MISSION
The International Committee of the Red Cross (ICRC) is an impartial, neutral and
independent organization whose exclusively humanitarian mission is to protect the
lives and dignity of victims of war and internal violence and to provide them with
assistance. It directs and coordinates the international relief activities conducted
by the Movement in situations of confict. It also endeavours to prevent suffering
by promoting and strengthening humanitarian law and universal humanitarian
principles. Established in 1863, the ICRC is at the origin of the International Red
Cross and Red Crescent Movement.
Acknowledgements:
Jean Franois Gallay
Leo Gasser
Pierre Gauthier
Frank Joumier
Jacques Lepetit
Bernard Matagne
Joel Nininger
Guy Nury
Peter Poestma
Hmayak Tarakhchyan

and all prosthetists-orthotists who have worked in ICRC-assisted physical rehabilitation centres.
1 Manuf actur i ng Gui del i nes Knee-Ankl e-Foot Or thosi s
Table of contents
Foreword 2
Introduction 4
1.Casting,measurementandrectifcation 4
2.Preparationofreinforcements 6
3.Polypropylenedrapingandvacuummoulding 7
4.Positionofthesidebars 9
5.Trimlines 11
6.Assemblyandparallelism 12
7.Initialfttings 13
8.Finishing 14
9.KAFOoptions 15
Listofcomponentsandmaterials 16
2 I CRC Physi cal Rehabi l i tati on Programme
Foreword
The ICRC polypropylene technology
Sinceitsinceptionin1979,theICRCsPhysicalRehabilitationProgrammehaspromotedtheuse
oftechnologythatisappropriatetothespecifccontextsinwhichtheorganizationoperates,
i.e.,countriesafectedbywarandlow-incomeordevelopingcountries.
Tetechnologymustalsobetailoredtomeettheneedsofthephysicallydisabledinthecountries
concerned.
Tetechnologyadoptedmustthereforebe:
durable,comfortable,easyforpatientstouseandmaintain;
easyfortechnicianstolearn,useandrepair;
standardizedbutcompatiblewiththeclimateindiferentregionsoftheworld;
low-costbutmodernandconsistentwithinternationallyacceptedstandards;
easilyavailable.
Techoiceoftechnologyisofgreatimportanceforpromotingsustainablephysicalrehabilitation
services.
Forallthesereasons,theICRCpreferredtodevelopitsowntechniqueinsteadofbuyingready-made
orthopaediccomponents,whicharegenerallytooexpensiveandunsuitedtothecontextsinwhich
theorganizationworks.TecostofthematerialsusedinICRCprostheticandorthoticdevices
islowerthanthatofthematerialsusedinappliancesassembledfromcommercialready-made
components.
WhentheICRClauncheditsphysicalrehabilitationprogrammesbackin1979,locallyavailable
materialssuchaswood,leatherandmetalwereused,andorthopaediccomponentswere
manufacturedlocally.Intheearly1990stheICRCstartedtheprocessofstandardizingthe
techniquesusedinitsvariousprojectsaroundtheworld,forthesakeofharmonizationbetweenthe
projects,butmoreimportantlytoimprovethequalityofservicestopatients.
Polypropylene(PP)wasintroducedintoICRCprojectsin1988forthemanufactureofprosthetic
sockets.Tefrstpolypropyleneknee-jointwasproducedinCambodiain1991;othercomponents
suchasvariousalignmentsystemswerefrstdevelopedinColombiaandgraduallyimproved.In
parallel,adurablefoot,madeinitiallyofpolypropyleneandEthylVinylAcetate(EVA),andnowof
polypropyleneandpolyurethane,replacedthetraditionalwooden/rubberfoot.
In1998,afercarefulconsideration,itwasdecidedtoscaledownlocalcomponentproductionin
ordertofocusonpatientcareandtrainingofpersonnelatcountrylevel.
3 Manuf actur i ng Gui del i nes Knee-Ankl e-Foot Or thosi s
Objective of the manuals
TeICRCsManufacturingGuidelinesaredesignedtoprovidetheinformationnecessaryfor
productionofhigh-qualityassistivedevices.
Temainaimsoftheseinformativemanualsareasfollows:
TopromoteandenhancestandardizationofICRCpolypropylenetechnology;
Toprovidesupportfortrainingintheuseofthistechnology;
Topromotegoodpractice.
Tisisanotherstepforwardintheeforttoensurethatpatientshaveaccesstohigh-qualityservices.
ICRC
AssistanceDivision/HealthUnit
PhysicalRehabilitationProgramme
4 I CRC Physi cal Rehabi l i tati on Programme
Introduction
Teaimofthisdocumentistodescribeamethodforproducingknee-ankle-foot orthoses (KAFO),
workingwithpolypropylenetechnologyandcommercialuprightsidebarswithdroplocksasusedat
theICRCsphysicalrehabilitationcentres.
Tecastingandrectifcationmethodsusedcorrespondtointernationalprostheticandorthotic
(P&O)standardsofpracticeandarethereforenotdescribedintheseICRCmanufacturingguidelines.
Someimportantpointsshouldnevertheless
betakenintoaccount:
1.1 Anatomy and landmarks
4Malleoli
4Te1
st
and5
th
metatarsalheads
4Navicularbone
4Baseof5thmetatarsal,ifprominent
4Greattrochanter
4Medialtibialplateau
4Headoffbula
CAsTIng, meAsuRemenT And ReCTIFICATIOn 1
5 Manuf actur i ng Gui del i nes Knee-Ankl e-Foot Or thosi s
1.2 Cast rectifcation method
Oncerectifcationiscompleted,checkthefollowing:
4Teposteriorlinepassesthrough
1.themiddleofthethigh
2.themiddleoftheknee
3.themiddleoftheankle
4Heelandforefootarefatontheground
4Telaterallinepassesfromthegreattrochanterto
themiddleofthelateralmalleolus
6 I CRC Physi cal Rehabi l i tati on Programme
1.3 mechanical knee joint location
4Mechanicalaxesaredefnedinaccordancewith
P&Opractice,asshownhere.
Tepositiveplasterremainsinaverticalposition:
4Drivetwonailsintothemould
atthemechanicalkneeaxis(they
shouldprotrudeabout5mm)
4Pullanylonorcottonstocking
overthemould
4FixtheEVAreinforcement
accordingtothemeasurement
cardandrequirements
4Dustthestockingwithtalcum
powder
PRePARATIOn OF ReInFORCemenTs 2
7 Manuf actur i ng Gui del i nes Knee-Ankl e-Foot Or thosi s
POlyPROPylene dRAPIng And vACuum mOuldIng 3
Cuta5mmsheetofpolypropylene(PP)asfollows:
4Heatthepolypropyleneat
180for20to25minutes,
dependingonthethickness
ofthepolypropyleneandthe
performanceoftheoven.
Drapethepolypropyleneover
theplastermodel.Laythe
polypropyleneoverthemould
withoutstretchingit.
CleanthePPsheet.
4Uppercircumference
+10cm
4Totallength
+20cm
4Lower
circumference
+15cm
3
1
2
3
2
1
Drapeitfrstovertheankletowards
themiddleanteriorpartoftheorthosis
mould.Tenpullitaroundtheforefoot.
8 I CRC Physi cal Rehabi l i tati on Programme
4Stickittogetheralongthe
anteriorside.
4Tightenthepolypropylene
aroundthesuctionconewith
aropeorsomethingsimilar.
Openthevacuumvalve.
4Withscissorsoraknife,cut
oftheexcesspolypropylene
alongtheweldingseamwhile
itisstillhot.
9 Manuf actur i ng Gui del i nes Knee-Ankl e-Foot Or thosi s
Remarks
Ifthepolypropylenesheetcutaccordingtothemeasurementsoftheplasteristoobigtoftintothe
oven,preparetwoPPsheetsinsteadofone.
DrapethePParoundtheplastermould.
Payattentiontotheoverlaparea,pullingthePPgraduallyandcarefully;otherwiseitwillbe
stretchedtoothinlyandbetooweak.
OpenthevacuumvalveandremovetheexcessPPalongtheseam.
POsITIOn OF The sIde bARs 4
4Onthebench,thepositivemould
isinstalledasfollows:
4Tepositionofthekneeaxis
shouldbemarkedinrelationto
theverticallineindicatingthe
locationofthemechanicalknee
joint.
kneeaxis
10 I CRC Physi cal Rehabi l i tati on Programme
4Teuprightsarecuttothe
requiredlength,bentand
adjustedfollowingthecurvesof
thePPshells.
11 Manuf actur i ng Gui del i nes Knee-Ankl e-Foot Or thosi s
4Duringadjustmentofthesidebars,the
positionandparallelismofthekneeaxis
mustberespected.
Axislocationandtrimlines
4Trimlinesdependonthetypeofcorrection
requiredandthefunctionoftheKAFO.
Inmostcases,trimlinesshouldbedrawn
accordingtointernationalP&Ostandards,as
shownhere:
TRIm lInes 5
12 I CRC Physi cal Rehabi l i tati on Programme
4Tepolypropyleneiscutofandthetrimlinecontours
aregroundandpolishedbeforetemporaryassemblyof
theKAFOfortrial.
Assembly And PARAllelIsm 6
4Tesidebarsaretemporarilyfxedonthe
polypropyleneshellswithM3screwsand
nuts.
Preciseparallelismofthekneejointisoftheutmostimportanceandmustbeensuredbeforethefrst
fttingasfollows:
4method 1:UsingaVerniercalliper
13
InITIAl FITTIngs 7
Manuf actur i ng Gui del i nes Knee-Ankl e-Foot Or thosi s
4method 2:Usingthecentringpin
4StraptheKAFOonthepatientslowerlimb.
4Checkthetrimlinesbeforethepatient
standsup.
Oncetheshoesareon,thepatientstands
upandgaittrainingcanbegin.
14 I CRC Physi cal Rehabi l i tati on Programme
FInIshIng 8
4Testrapsarefxedwithtubularrivets
4Tetrimlinesarecarefully
polished
4Teuprightscanbecoveredwithfne
leather
4Teparallelismofthekneejointis
checkedagain
4Teuprightsarefxedwithcopper
rivets
15
KAFO OPTIOns 9
Manuf actur i ng Gui del i nes Knee-Ankl e-Foot Or thosi s
4TeKAFOisreadyfordelivery
4Somepatients
needanischial
seatsupport.
Inthiscasethe
brimhasan
anterioropening.
Teshapeis
similartothat
ofquadrilateral
socketprosthesis.
4TeKAFOcanbe
fttedwithdiferent
orthoticjoints
(Swisslock,drop
lock,freeofset,
etc.).
16 I CRC Physi cal Rehabi l i tati on Programme
ICRC Code Description
Unit of
measure
Quantity
For negative and positive cast :
ODROSTOCOT60 Tubular stockinet, 60 cm Cm 135
MDREBANDP10-12-15 Plaster of Paris bandages10, 12 or 15 cm x 3 m Piece 6 to 7
OTOOPLASPW40 Plaster of Paris powder Each As required
For EVA and plastic moulding :
OPLAEVAFKIN06 EVA FOAM 6 mm x 0.95 m x 0.95 m, 0.90 m
2
, skin colour Sheet 0
OPLAPOLYSKIN 04 HOMOPOLYMER 4 mm or 5 mm x 1 m x 2 m 7.5 kg, beige colour Sheet 0.5
For components/ sidebars:
OCPOKNEEB20DL/16DL ORTHOSIS, ADULT, 20 mm or 16 mm side bar knee joint w.drop lock (pairs) Pair 1
OCPOKNEEBO20SL/16SL ORTHOSIS, ADULT, 20 mm or 16 mm side bar knee joint, Swiss lock (pairs) Pair 1
OCPOKNEEBO20DL/16DL ORTHOSIS, ADULT, 20 mm or 16 mm side bar knee joint w.drop lock (pairs) Pair 1
For straps and rivets:
OSBOVSBO26 ELASTIC STRAP 25 mm x 25 m Roll 0.02
EHDWZBAKGLUE01 GLUE, SYNTHETIC Litre 0.2
OSBOVSBO36 LOOP 35 mm x 100 pcs Box 0.04
EBUIZBAKPOPPOWD PLASTER POWDER Kg 12
EHDWOHPW45 RIVET (COPPER) 4 mm x 20 mm x 1,000 pcs Box 0.012
EHDWOHDW40 RIVET (TUBULAR) 13 mm x 12 mm x 1,000 pcs Box 0.012
ORTOZBAKSPAR SANDPAPER 15 x 15 Piece 1
OSBOVSBO29 STRAP (PROSTHESIS) 35 mm x 50 m Roll 0.02
OSBOVSBO25 STRAP (VELCRO) 30 mm M 1
OOMAALIGORTH CENTRING PIN FOR ORTHOSIS 1 30
ETOOMEASC15 VERNIER CALLIPER 1 35
Special hand tools:
OTOOMEASCIR4 _ 7 COUNTOURING INSTRUMENT, ROUND BEAK Each 2
OTOOMEASCFL COUNTOURING INSTRUMENT, FLAT Each 2
OOMAALIGORTHX CENTRING PIN FOR ORTHOSIS Each 1
ETOOMEASC15 VERNIER CALLIPER Each 1
list of components and materials
MISSION
The International Committee of the Red Cross (ICRC) is an impartial, neutral and
independent organization whose exclusively humanitarian mission is to protect the
lives and dignity of victims of war and internal violence and to provide them with
assistance. It directs and coordinates the international relief activities conducted
by the Movement in situations of confict. It also endeavours to prevent suffering
by promoting and strengthening humanitarian law and universal humanitarian
principles. Established in 1863, the ICRC is at the origin of the International Red
Cross and Red Crescent Movement.
Acknowledgements:
Jean Franois Gallay
Leo Gasser
Pierre Gauthier
Frank Joumier
Jacques Lepetit
Bernard Matagne
Joel Nininger
Guy Nury
Peter Poetsma
Hmayak Tarakhchyan

and all prosthetists-orthotists who have worked in ICRC-assisted physical rehabilitation centres.
International Committee of the Red Cross
19 Avenue de la Paix
1202 Geneva, Switzerland
T + 41 22 734 60 01 F + 41 22 733 20 57
E-mail: icrc.gva@icrc.org
www.icrc.org
ICRC, September 2006
All photographs: ICRC/PRP
Physical Rehabilitation Programme
ankle-Foot orthosis
Manufacturing guidelines
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