A. (1) II linger» or toes become swollen blue, painful or stiff, raise limb.
(21 If no improvement in half an hour call in Doctor or return to hospital immediately.
B. |ii lixercisc all joints not included in plaster—especially fingers and toes
(2) If you hnve been fitted with a walking plaster walk in it.
(3) If plaster becomes loose or cracked—report to hospital as soon as possible.
46. The patient who is being allowed home must be given clear warnings to return should the circulation appear in any way to be impaired. Inform the patient or. where appropriate, a relative who will be looking after the patient. It is also useful to reinforce this by pasiing an instruction label (such as the one illustrated) directly to the plaster.
(a): Is there swelling'.' Swelling of the lingers or toes is common in patients being treated in plaster, hul the patient must he examined carefully for other signs which might suggest that circulatory impairment is Ihe cause, rather than Ihe local response to trauma. If there is no evidence of circulatory impairment, the limb should be elevated and movements encouraged.
48. Aftercare (b): Is there discoloration of the toes or fingers? Compare one side with the other; bluish discoloration, especially in conjunction with oedematous swelling distally. suggests lhat swelling of Ihe limb within the plaster has reached such a level as to impair the venous return, and appropriate action must be taken.
49. Aftercare (c): Is there any evidence of arterial obstruction '.' Note the live I's: intense piiin, paralysis of finger or toe flexors, puniesthesiue in fingers or toes, pallor of the skin with disturbed capillary return, and perishing cold' feel of the fingers and toes. Arterial obstruction requires immediate, positive action. (Clinical findings of a similar nature, along with pain on passive movements of the lingers or toes, is found in the compartment syndromes: see p. 99.)
50. Treatment of suspected circulatory impairment (a): Elevate the limb (I). In the ease of a plaster slab, cut through the encircling bandages and underlying wool (2) until the skin is fully exposed, and ease back the edges of the plaster shell until it is apparent that il is not constricting the limb in any way.
51. Treatment (b): Where the plaster is a complete one. split the plaster throughout its entire length. Ease back the edges of the cast to free the limb on each side of the midline. Divide all the overlying wool and stockinet and turn it back till skin is exposed. The same applies Hi any dressing swabs hardened with blood clot.
52. Treatment (c): If the circulation has been restored, gently pack wool between Ihe cut edges of Ihe plaster (1) and firmly apply an encircling crepe bandage (2). If this is not done, there is risk of extensive skin ('plaster') blistering locally. If the circulation is not restored, reappraise the position of the fracture and suspect major vessel involvement. On no account adopt an expectant and procrastinating policy.
53. Aftercare (d): Can the plaster he completed'.' If Ihe plaster consists of a back slab or shell, completion depends on your assessment of the present swelling, and your prediction of any further swelling. Most plasters may be completed after 48 hours: but if swelling is very marked completion should be delayed for a further 2 days, or until il is showing signs of subsiding.
54. Aftercare (e): Is the plaster intact? Look for evidence of cracking, especially in the region of the joints (I). In arm plasters, look for anterior softening (2) and softening in the palm (3). In the leg. look for softening of Ihe sole piece f4). the heel (S) and calf (6). Any weak areas should be reinforced by the application of more plaster locally.
55. Aftercare (f): Is the plaster causing restriction of movement'.' Look especially for encroachment of the palm piece on the ulnar side of the hand, restricting MP joint flexion (1). In forearm plasters, look also for restriction of elbow movements. In below-knee plasters, note if the plaster is digging in when the knee is Hexed (2). Trim the plaster as appropriate (3).
58. Aftercare (i): Has the plaster become too loose? cntcl In the leg, grasp the plaster and pull it distally: note how far the toes disappear into the plaster. If a plaster is loose, it should be changed unless ti) union is nearing completion and risks of slipping are minimal or (ii) a good position is held and the risks of slipping while the plaster is being changed are thought to be greater than the risks of slipping in a loose plaster.
56. Aftercare (g): Is the plaster too short '/ Note especially the Colles-type plaster with inadequate grip of the forearm (I); note the below-knee plaster which does not reach the tibial tuberosity (2) and which, apart from affording unsatisfactory support of an ankle fracture, will inevitably cause friction against the shin. Extend the defective plasters where appropriate (3).
59. Aftercare (j): Is the patient complaining of localised pain'.' Localised pain, especially over a bony prominence, may indicate inadequate local padding, local pressure and pressure sore formation. In a child it may sometimes suggest a foreign body pushed in under the plaster. In all eases, the affected area should be inspected by cutting a window in the plaster and replacing it alter examination.
57. Aftercare (h): Has the plaster become too loose '/ A plaster may become loose as a result of the subsidence of limb swelling and from muscle wasting. If a plaster is slack, then the support afforded It) the underlying fracture may become inadequate. Assess looseness by attempting to move the plaster proximally and distally. while noting its excursion in each direction.
60. How to remove a plaster - plaster slabs: Plaster shells or slabs are easily removed by cutting the encircling open weave bandages which hold them in position. Care must be taken to avoid nicking the skin, and Bolder scissors are helpful in this respect.
61. Removing complete plasters -Using shears (a): The heel of the shears must lie between the plaster and the linih. Subcutaneous bony prominences such as the shaft of the ulna (I) should he avoided to lessen the risks of skin damage and pain. Instead, the route of the shears should be planned to lie over compressible soft tissue masses (2).
64. Using shears (d): Keep the lower handle tL> parallel to the plaster, or even a little depressed, t.ifl up the upper handle (U); push the shears forward with the lower handle so that the plaster lills the throat ol the shears. Maintaining a slight pushing force - all the culling action may be performed with the upper handle, moving il up and down like a beer pump.
62. Using shears (b): If possible, avoid cutting over a concavity. If the wrist is in moderate palmar llexion. as in a Colics plaster, the plaster should be removed by a dorsal cut (I). In a scaphoid plaster, the dorsal route should be avoided (2) and the plaster removed anteriorly.
65. Using a plaster saw (a): Piaster saws may be used for removing or cutting w indows in plasters, but they should be used w ith caution and treated w ith respect. Do not use a plaster saw' unless there is a layer of wool between the plaster and the skin. Do not use it over bony prominences and do not use if the blade is bent, broken or blunt. Note: the blade does not rotate hut oscillates.
63. Using shears (c): Where there is the right-angled bend of the ankle to negotiate, it is often helpful to make two vertical cuts dow n through the sole piece (I) and turn il down (2). This then gives access for the shears to make a vertical cut behind the lateral malleolus (3) and then skirt forwards over the peronei (4). The remaining plaster may ihen be sprung open.
66. Using a plaster saw (b): Electric saws are noisy, and ihe apprehensive patient should he reassured. Cut down through the plaster at one level (I); the note will change as soon as it is through. Remove the saw (2) and shift it laterally about 2.5 cm (3), and repeal (4). Do not slide Ihe saw laterally in shallow cuts: the culling movement should he up and down.
67. Polymer resin casts: Most use bandages of cotton (e.g. Bayer's Baycast"*), tihreglass (Smith & Nephew's Dynacast XR ) or polypropylene (3M's Primacast®). impregnated with a resin which hardens on contact with water. Advantages include: I. Strength combined with lightness. 2. Rapid setting (5-10 mini and curing, reaching maximum strength in 30 min (cf. plasters whose slow 'drying out' period of about 48 hours may lead, if unprotected, to cracking). 3. Water resistance combined with porosity (although welting of the inner layers should still be avoided). 4. Radiolucence.
Disadvantages include: I. High item cost but their durability reduces demands on staff and transport. 2. They generally mould less well than plaster, and are more unyielding.
After acute injuries, where further swelling is likely, plaster is generally the more suitable easting material: it can be carefully moulded to the pan giving particularly good support, and where necessary it can be applied in the form of a slab. When swelling subsides, and the stability of the fracture is not in doubt, a resin cast may be substituted. Where little swelling is anticipated in a stable fresh fracture, a resin cast may be used from the outset. Where a cast is likely to be abused (e.g. in wet weather where an extroverted teenager requires support for an ankle injury) there is much to be said for using a resin cast, and of course it is possible to reinforce an ordinary plaster cast with an outer resin bandage.
70. Application (c): linsure the limb is correctly positioned, and apply each turn so that it overlaps the one beneath by half a width (I). It is permissible to use a figure-of-eight (2) round the ankle, elbow and knee to assist the bandage to lie neatly in conformity with the contours of the limb beneath. Turn back the stockinet (3) before applying the top layers of the bandage, and make quite certain that there will be no sharp or hard cast edges which can cause ulceration of the skin.
68. Application (a): Apply conforming stockinet (I) to the liinb: ensure that it extends 3-5 cm (12") beyond the proposed limits of the cast itself (2). Next, apply a layer of padding (3). paying particular care to protect the bony prominences. Where it is necessary to resist exposure to water or to moisture, a synthetic water-resistant orthopaedic padding may be used (e.g. Smith & Nephew's Soffban").
71. Application (d): In some cases close moulding of the east may be encouraged by the temporary application of a firm external bandage. For this a thick cotton or crepe bandage may be used. This is first welted, and then wrapped tightly round the limb. This will also be found helpful in retaining the last turn or two of the resin bandages, which often have a disturbing tendency to peel away before they set. Remove the wet overbandagc once the east has set.
69. Application (b): Open each bandage pack only as required to avoid premature curing. Wear gloves to prevent the resin adhering to your skin or causing sensilisalion. Immerse the bandage in warm water for 2-5 seconds, squeezing it two to four times lo accelerate setting. Fewer bandages will be required than with plaster, e.g. a below-knee east in an adult may be applied with two 7.5 cm (3") and one lo two 10 cm (4") bandages. Use the smaller sizes for the areas requiring a high degree of conformity (e.g. the ankle).
72. Removal of resin casts: Because of their inherent springiness, resin casts cannot be cracked open after they have been cut down one side, as can plasters. In most cases it is necessary to bivalve by cutting down both sides. In the case of leg casts, it is best to turn down the sole piece first. Either shears or an oscillating saw may be used: in the latter case, a dust extractor should be employed to avoid the inhalation of resin dust. Resin casts are less likely to break after windowing than plasters.
73. Assessment of union (a): Union in a fracture cannot be expected until a certain amount of time has elapsed, and it is pointless to start looking too soon. (See individual fractures for guidelines.) When il is reasonable lo assess union, the limb should be examined out of plaster. Persistent oedema at the fracture site suggests union is incomplete.
74. Assessment of union (b): hxamine the limb carefully for tenderness Persistent tenderness localised to the fracture site is again suggestive of incomplete union.
75. Assessment of union (c): Persistent mobility at the fracture site is ccnain ev idence of incomplete union. Support the limb close to the fracture with one hand, and with the other attempt to move the distal part in both the anterior and lateral planes. In a uniting fracture this is not a painful procedure.
76. Assessment of union (d): Although clinical assessment is often adequate in many fractures of cancellous bone, il is advisable, in the case of the shafts of the femur, tibia, humerus, radius and ulna, to have up-to-date radiographs of the region. The illustration is of a double fracture of the femur at 14 weeks. In the proximal fracture, the fracture line is blurred and there is external bridging callus of good quality: union here is fairly far advanced. In the distal fracture, the fracture line is still clearly visible, and bndging callus is patchy. Union is incomplete, and certainly not sufficient to allow unprotected weight bearing.
In assessing radiographs for union, be suspicious of unevenly distributed bndging callus, of a persistent gap, and of sclerosis or broadening of the bone ends. Note that where a particularly rigid system of internal fixation has been employed, bridging callus may be minimal or absent, and endosteal callus may be very slow to appear.
If in doubt regarding the adequacy of union, continue with fixation and re-examine in 4 weeks.
Note thai in all cases you must assess whether the forces the limb is exposed to will result m displacement or angulation of the fracture, or cause such mobility thai union w ill he prevented. You must therefore balance the following equation:
KxU-rnul forces < (degree of union + support supplied by any iiitcrnul fixation device and/or external splintage).
Open fractures 70
Immediate treatment 70 Wound management 70
Degloving injuries 71 Principles of internal fixation 72 Cortical bone screws 74 Plates 74
Cancellous bone screws 76 Blade plates 77 Dynamic hip and condylar screws 77 Intramedullary nails 77 Tension band wiring 78 External fixators 78 Internal fixation in open fractures 79 Gunshot wounds 80
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