Casts, Splints, And Support Bandages Nonoperative Treatment And Perioperative Protection

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Klaus Dre sing

Pe te r Trafton

os Enge le n Cast Te chnician

Casts, Splints, and Support andage s— Nonope rative Tre atme nt and Pe riope rative Prote ction

Klaus Dre sing

Pe te r Trafton

os Enge le n Cast Te chnician

Casts, Splints, and Support andage s— Nonope rative Tre atme nt and Pe riope rative Prote ction Include s

illustrations and im age s and

vide os

ibrar of Congre ss Cataloging in Publication Data will be available from the publishe r

Ha za rd s re at care has be e n ta e n to m aintain the accurac of the inform ation containe d in this publication owe ve r, the publishe r, and or the distributor, and or the e ditors, and or the authors cannot be he ld re sponsible for e rrors or an conse ue nce s arising from the use of the inform ation containe d in this publication Contributions publishe d unde r the nam e of individual authors are state m e nts and opinions sole l of said authors and not of the publishe r, and or the distributor, and or the AO roup The products, procedures, and therapies described in this wor are ha ardous and are the re fore onl to be applie d b ce rti e d and traine d m e dical profe s sionals in e nvironm e nts spe ciall de signe d for such proce dure s No sugge ste d te st or procedure should be carried out unless, in the user s professional udg ment, its ris is usti e d hoe ve r applie s products, proce dure s, and the rapie s shown or de scribe d in this wor will do this at the ir own ris e cause of rapid advances in the medical sciences, AO recommends that independent veri cation of diagnosis, the rapie s, drugs, dosage s, and ope ration m e thods should be m ade be fore an action is ta e n Although all adve rtising m ate rial which m a be inse rte d into the wor is e xpe cte d to conform to e thical m e dical standards, inclusion in this publication doe s not constitute a guarante e or e ndorse m e nt b the publishe r re garding ualit or value of such product or of the claim s m ade of it b its m anufacture r

Le g a l re s trictio n s This wor was produce d b AO oundation, Swit e rland All rights re se rve d b AO oundation This publication, including all parts the re of, is le gall prote cte d b cop right An use , e xploitation or com m e rciali ation outside the narrow lim its se t forth b cop right le gislation and the re strictions on use laid out be low, without the publisher s consent, is illegal and liable to prosecution This applies in particular to photostat re production, cop ing, scanning or duplication of an ind, translation, pre paration of m icro lm s, e le ctronic data proce ssing, and storage such as m a ing this publication available on Intrane t or Inte rne t Som e of the products, nam e s, instrum e nts, tre atm e nts, logos, de signs, e tc re fe rre d to in this publication are also prote cte d b pate nts and trade m ar s or b othe r inte lle ctual prope rt prote ction laws e g, AO , ASI , AO ASI , T IAN E O E ogo are re giste re d trade m ar s e ve n though spe ci c re fe re nce to this fact is not alwa s m ade in the te xt The re fore , the appe arance of a nam e , instrum e nt, e tc without de signation as proprie tar is not to be construe d as a re pre se ntation b the publishe r that it is in the public dom ain e strictions on use The rightful owne r of an authori e d cop of this wor m a use it for educational and research purposes onl Single images or illustrations m a be copie d for re se arch or e ducational purpose s onl The im age s or illustrations m a not be alte re d in an wa and ne e d to carr the following state m e nt of origin Cop right b AO oundation, Swit e rland Che c ha ards and le gal re strictions on www aofoundation org le gal

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b AO oundation, Swit e rland, Clavade le rstrasse , C Davos Plat e org Thie m e e rlag, dige rstrasse , DE Stuttgart and Thie m e Ne w or ,

Se ve nth Ave nue , S Ne w or , N

a out nougat m b , C ase l Illustration AO Education Institute IS N e IS N

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

ore word

oreword

o

as

e di, MD, ACS

ounding Member AO oundation Consultant AOTrauma Education Schellenbergstr

, Im risig

Maienfeld Swit erland

Fin ally, a ter m an y attem pts an d w ith great an ticipation , AOTrau m a h as provided a pu blication speci cally on n on operative ractu re treatm en t. Th is book Casts, Splints, and Support Bandages— Nonoperative Treatment and Perioperative Protection is an in dication th at “AO” does n ot stan d or “Alw ays Operate” bu t rath er or a com preh en sive approach to th e variou s treatm en t option s or m u scu loskeletal in ju ries. Th e tw o editors, rom Germ an y an d th e US, togeth er w ith 20 au th ors rom arou n d th e w orld, h ave produ ced a book th at covers all th e m ajor issu es on th e topic in a very didactic an d sel -explan atory w ay. A ter an in trodu ction to th e basic prin ciples o castin g, th e gu idelin es an d in dication s o n on operative ractu re m an agem en t are discu ssed critically based on th e AO classi cation . Th ere are in depth ch apters abou t th e treatm en t o ractu res in th e u pper an d low er extrem ities, w h ile th e ch apters on in ju ries o th e ligam en ts, an d as a resu lt o overload, are w ell ch osen . Oth er im portan t aspects discu ssed in clu de pediatric ractu res, a m ain dom ain o n on operative treatm en t, as w ell as th e m an agem en t o spin e in ju ries. Fin ally, th e tech n iqu es o cast, splin t, an d ban dage application are illu strated step-by-step or location s th rou gh ou t th e u pper an d low er extrem ities, as w ell as th e spin e, u sin g di eren t xation m aterials.

Th e au th ors are to be con gratu lated or th e very detailed presen tation o th e variou s tech n iqu es by tw o m asters in castin g, w h ich is m ost h elp u l especially or all th ose th at h ave n ot h ad th e ch an ce to learn th e special “art o castin g” w ith its m an y im portan t tricks an d h in ts. I applied correctly by an expert, n on operative treatm en t can be su perior an d pre erable to poorly attem pted su rgery in m an y types o ractu res, especially so in developin g cou n tries w h ere th e risk o in ection a ter su rgery is still very h igh an d m u ch m ore problem atic th an a m in or m alalign m en t or even a n on u n ion . Th is book sh ou ld n d its place on th e sh el o every castin g room , at th e disposal o residen ts an d tech n ician s, an d or su rgeon s requ irin g u p to date kn ow ledge on th e latest castin g tech n iqu es. Th o m as P Rü e d i

Ac nowle dgeme nts

Ac nowledgements

Casts, Splints, and Support Bandages — Nonoperative Treatment and Perioperative Protection w ou ld n ot h ave been possible w ith ou t th e dedicated assistan ce an d su pport o a w on deru lly diverse grou p o people. From th e edu cation design , developm en t an d lm in g o videos, m edical an d graph ical illu stration s, research an d text developm en t, editin g an d proo readin g, typesettin g, an d n al com pletion an d prin t produ ction , th is book h as in deed been a labor o love or w h ich w e w ou ld like to th an k m an y people. To begin , w e w ou ld like to especially ackn ow ledge th e ollow in g: • Urs Rü etsch i, Director o th e AO Edu cation In stitu te, as w ell as th e m em bers o th e AOTrau m a Edu cation Com m ission , or acceptin g an d su pportin g th e idea to develop th is com preh en sive text, an d or providin g exten sive resou rces to do so • Th e AO Edu cation In stitu te Video Produ ction Team , led by Robin Green e, or h elpin g u s to coordin ate an d lm ou r exten sive ran ge o dem on stration videos, an d a very special th an ks to Mike Law s or h is cou n tless h ou rs spen t in th e editin g su ite, com pilin g an d editin g raw ootage an d tu rn in g it in to clear an d h igh ly pro ession al m edical procedu re dem on stration s • Ou r dedicated au th ors, w h o don ated m an y h ou rs research in g an d developin g th eir ch apters in th eir ow n rare spare tim e • Pro Dr Th om as Rü edi, on e o th e ou n ders o AO Fou n dation , w h o su pported th e idea or th is book an d kin dly w rote h is dedicatory orew ord • We especially th an k ou r tireless an d dedicated colleagu e Jos En gelen , n ot ju st or h is expertise in cast an d splin t application , h is starrin g role in th e dem on stration videos, an d h is th orou gh an d precise editorial su pport in m an y o th e ch apters, bu t or h is con stan t availability an d rien dsh ip th rou gh ou t every stage o th is text

I

• Kath rin Lü ssi rom th e AO Edu cation In stitu te, an d Cristin a Lu sti an d Mich ael Gleeson , ou r h ard w orkin g Project Coordin ators, w h o provided in valu able adm in istrative an d editorial su pport to u s th rou gh ou t th e li e o th e project • Tom Wirth , Jecca Reich m u th , an d Olivier Jallard or th eir exception al w ork in design in g an d illu stratin g th e book, as w ell as to th e sta at AO Su rgery Re eren ce • Ou r typesetters Nou gat, ou r lan gu age editor Barbara Gern ert, an d ou r partn er pu blish er Th iem e Pu blish in g or prin t produ ction an d distribu tion • Carl Lau an d Su e Klein or proo readin g • Ou r trem en dou s cast o video dem on stration m odels, com prisin g En dre Varga Jr, Priska In au en , Fabian Du tten h oe er, Sebastian Fäh , Kath rin Lü ssi, an d Cristin a Lu sti • Th e AO Socioecon om ic Com m ittee, as stead ast su pporters o n on operative ractu re m an agem en t in th e less-developed parts o th e w orld • 3M Germ an y, or providin g syn th etic castin g m aterials or th e video lm in g • Loh m an n & Rau sch er, Germ an y, or providin g plaster o Paris castin g m aterials or th e video lm in g • Berger Medical Produ cts, or th e u se o im ages o cast in stru m en ts • An dreas Wu f i rom th e Un iversity Hospital Zü rich , or providin g u s w ith cast tables an d equ ipm en t or th e video lm in g • An d n ally to ou r ow n partn ers an d am ilies, w ith ou t w h ose u n qu estion in g su pport w e cou ld n ever h ave been able to brin g togeth er th is im portan t m edical text. Ou r sin cere th an ks to each o you . Klau s D re sin g, Pe t e r Traft o n

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Pre face

Preface la u s

I rem em ber bein g in trodu ced to n on operative ractu re treatm en t du rin g m y residen cy in Dü sseldor , Germ an y. We treated alm ost 60% o ractu res con servatively. I later pu rsu ed u rth er train in g in a level-1 trau m a cen ter w h ere n on operative care w as tau gh t w ell, an d practiced sign i can tly. As residen ts th ere, each o u s w as assign ed to teach a plaster cou rse or m edical stu den ts. Over tim e, w e began to in clu de syn th etic cast m aterial an d in n ovative n ew tech n iqu es in to ou r practice an d teach in g. As a acu lty m em ber at th e Un iversity Medical Cen ter in Göttin gen , Germ an y, I h ave alw ays in clu ded cast application as a part o m y th erapeu tic arm am en t. Ou r grou p h as developed in creasin gly soph isticated tech n iqu es, u sin g plaster o Paris, as w ell as syn th etic m aterials in both rigid an d sem irigid orm s. Th is am iliarity w ith th e u se o variou s castin g tech n iqu es, as a su rgeon , an d as a teach er, m ean t th at I w as w ell prepared, an d greatly h on ored, to accept AOTrau m a' s in vitation to u n dertake th is excitin g an d w orth w h ile book an d video project Casts, Splints, and Support Bandages— Nonoperative Treatment and Perioperative Protection. An d it w as a h appy coin ciden ce th at led to m y collaboration w ith Peter Tra ton . Several years ago, m y w i e Petra (a qu ilt m aker) an d I h eld a ch arity au ction , “Qu ilts or Malaw i”, to su pport a ch ildren ' s h ospital in Blan tyre, Malaw i, in sou th east A rica. Th rou gh ou r in depen den t AOTrau m a activities, Peter an d I began to m eet regu larly, an d I soon learn ed th at, in credibly, h e h ad also visited Blan tyre as a volu n teer orth opedic su rgeon . We sh ared ou r experien ces in th e developin g w orld, w h ere n an cial con strain ts lim it th e u se o osteosyn th esis. We agreed th at th e AO n eeded u p-to-date teach in g resou rces or im m obilization tech n iqu es, as altern atives an d as su pplem en ts to operative ractu re treatm en t, as w ell as or oth er orth opedic con dition s. Havin g ou n d a kin dred spirit, I w as deligh ted w h en Peter accepted m y in vitation to join m e as co-editor.

Pe t e r

Like Klau s, m y train in g in trau m a an d orth opedic su rgery began early in th e tran sition rom n on operative treatm en t to m odern practice, w ith its ar greater em ph asis on th e su rgical stabilization o ractu res. Operative ractu re care is in deed su ccess u l w h en practiced e ectively an d sa ely, an d w orldw ide, w e h ave adopted cou n tless n ew in tern al an d extern al xation tech n iqu es, to w h ich th e AO com m u n ity h as con tribu ted so m u ch . How ever, th e u n in ten ded con sequ en ce is th at edu cators an d su rgical train ees h ave devoted so m u ch tim e, en ergy, an d atten tion to developin g operative skills th at n on operative tech n iqu es h ave been le t to w ith er aw ay. Bu t th ey are still a cru cial part o ou r patien t care, in rst-w orld trau m a cen ters, as w ell as everyw h ere else w h ere m u scu loskeletal in ju ries an d oth er disorders are en cou n tered an d treated. I am grate u l th at m y teach ers h elped m e acqu ire th is kn ow ledge an d skills, an d th at m y role as an edu cator h as h elped m e im prove m y u n derstan din g an d clin ical practice. As a residen t, I w as privileged to w ork w ith Vert Moon ey at Ran ch o Los Am igos, an d su bsequ en tly to develop collegial relation sh ips w ith Au gu sto Sarm ien to an d Loren Latta, w h o h ave con tribu ted so m u ch to u n ction al ractu re bracin g. More recen tly, m y in volvem en t in volu n teer activities in low er an d m iddle in com e location s h ave brou gh t m e back to m y less-operative roots. In su ch settin gs, I am especially grate u l or w h at I learn ed as a you n g residen t. It is particu larly rew ardin g th at th e AO, su ch a stron g orce in th e developm en t o operative m u scu loskeletal care, h as em braced th is e ort to h elp preserve an d u rth er n on operative tech n iqu es as w ell. With ou t dou bt, a com plete su rgeon sh ou ld be equ ally skilled in both approach es. To ge t e r

In ou r great AO am ily, m an y rien ds an d colleagu es are in volved in n on operative ractu re care. We are deligh ted an d grate u l th at so m an y h ave su pported th is book w ith excellen t ch apters. With th eir h elp, w e o er you th is e ort to m ain tain expertise in n on operative im m obilization tech n iqu es, or u tu re gen eration s, an d or th e care o m u scu loskeletal an d so t tissu e con dition s today. Klau s D re sin g, Pe t e r Traft o n

II

Contributors

Contributors

d it o rs la s

re s ing Prof Dr me d

eitender Oberar t

e te r The

Klini f r nfallchirurgie, Plastische und

e org August

ttingen

niversit t

arren Alpert Me dical School of rown

niversit

ie derherstellungschirurgie niversit tsme di in

ra to n, Prof MD

ichmond Stre et Providence, I SA

obert Koch Strasse ttingen erman

Ca s t t e c n icia n o s nge le n Cast Te chnician ae sco O IC A Alter arten ever usen erman

III

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Contributors

u t o rs a

el

, MD M

la s

Consultant Orthopae dic and

and Surge on

eitender Oberar t

Chairman of the Orthopae dic Department ordan

re s ing Prof Dr me d

Klini f r nfallchirurgie, Plastische und

ospital and Me dical Center

niversit tsme di in

ue en Nour Stre e t

e org August

Amman

ie derherstellungschirurgie

ttingen

niversit t

obert Koch Strasse

ordan

ttingen erman

alte r

c inge r, em Prim Dr

ormer Chie f Ph sician of the Trauma

nit

rentenmaisstr

orn, ower Austria

le

e ns

o nt, PD Dr

e sch ftsf hrender Oberar t

olfsgraben

Klini f r nfallchirurgie und Orthop die

Austria

Abteilung f r nfallchirurgie, Plastische und niversit tsme di in

ate

i e r an, Prof PhD MD

niversit Clinical Center ubl ana

ttingen

e org August niversit t obert Koch Strasse

De partment for Traumatolog alos a

ie derherstellungschirurgie

ttingen erman

ubl ana Slovenia

o s nge le n Cast Te chnician

an

an e l o nc a ando al, MD

Orthopae dic Surge on

ae sco O IC A Alter arten

niversidad del Cauca

ever usen

acultad de Me dicina

erman

Calle Popa an

lo rian

Colombia

ard, niv Prof Dr me d

Dire ctor and Chair Department for Orthopae dic Trauma lm

ile s rancis

e

e la

o s a, MD POA PCS

niversit

entrum f r Chirurgie

Senior Consultant

Klini f r nfallchirurgie, and , Plastische und

Philippine Orthopae dic Center

Albert Einstein Alle e

Maria Clara Stre e t ue on Cit

iederherstellungschirurgie

lm erman

Philippine s

IX

Contributors

e ate

Hans o n, MD MP

as tian c e ide re r, Dr me d

Dire ctor AO Clinical Inve stigation and Documentation

lm

Ste ttbachstrasse

entrum f r Chirurgie

D bendorf

niversit

Klini f r nfallchirurgie, and , Plastische und

Swit erland

iederherstellungschirurgie

Albert Einstein Alle e lm

Harris o n, Prof MD

erman

Consultant in Trauma and Orthopae dics Counte ss of Che ster N S oundation Trust

an

iverpool road

ili

c

ttr

, Dr me d

Assisten ar t f r Orthop die und

Che ster

nfallchirurgie

Klini f r nfallchirurgie und Orthop die

nite d Kingdom

Abteilung f r nfallchirurgie, Plastische und niversit tsme di in

ic ard

do ls

, Prof Dr

AK ,

niversit t

hringer

ttingen

e org August niversit t

niversit ts lini f r nfallchirurgie Me di inische

ie derherstellungschirurgie

obert Koch Strasse

ien

ttingen

rtel

erman

ien Austria

ranz e i e rt, Prim Ao

niv Prof Dr Mag

Me dical Dire ctor a

i

o s e i , Prof MD

e ad of Orthopae dic Trauma adassah

K nit

ra , A

A

Te aching ospital of the Me dical niversit

niversit Me dical Center

ra

stingerstrasse

Ein Kerem

ra

PO ox

Austria erusalem

Israel

e te r The

o

as

e

a e r, Prim Dr

aldviertel lini um

ra to n, Prof MD arren Alpert Me dical School of rown

niversit

ichmond Stre e t

orn

Providence, I

nfallchirurgie

SA

Spitalgasse orn

ndre arga, Prof MD

Austria

Profe ssor of Trauma Surger ead of De partment of Traumatolog

e te r ic te r, Dr me d lm

Pre sident of ungarian Trauma Socie t

niversit

niversit of S e ge d

entrum f r Chirurgie

Albert S entg

Klini f r nfallchirurgie, and , Plastische und Albert Einstein Alle e lm

iederherstellungschirurgie

rg i Clinical Center

Department of Traumatolog S e ge d, Semmelweis u ungar

erman

X

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Abbre viations

Abbreviations

C C P T C C C P CT IP T B B C N SIN S P S pa IC I I N IN IP I IPC C C CP

acrom ioclavicu lar an terior cru ciate ligam en t an terior/ posterior an terior talo bu lar ligam en t calcan eo bu lar ligam en t cen ter o an gu lation c-reactive protein com pu ted tom ograph y distal in terph alan geal distal radiou ln ar join t deep vein th rom bosis eviden ce-based m edicin e eviden ce-based orth opedics electrocardiogram em ergen cy departm en t Eu ropean n orm elastic stable in tram edu llary n ailin g eryth rocyte sedim en tation rate f exor digitoru m pro u n du s f exor digitoru m su per cialis gigapascals o pressu re glen oh u m eral in tegu m en t closed (closed skin lesion ) in su lin -depen den t diabetes m ellitu s in tram edu llary n ailin g in tern ation al n orm alized ratio in terph alan geal in tegu m en t open (open skin lesion s) in term itten t pn eu m atic com pression lateral collateral ligam en t low -m olecu lar-w eigh t h eparin m edial collateral ligam en t m etacarpoph alan geal

pa I T TP NC NCS NIBP Nm NS I s N I P CS PC P P T PIP P P PP P TB PT CTs IC PS S

P

Sp T T C T BC

m egapascals o pressu re m agn etic reson an ce im agin g m u scle ten don in ju ry/ m u scle an d ten don lesion s m etatarsoph alan geal n erve con du ction velocity n erve con du ction stu dy n on in vasive blood pressu re m on itor New ton m eters n on steroidal an tiin f am m atory dru gs n eu rovascu lar in ju ry/ n erve an d vessel in ju ries operatin g room open redu ction an d in tern al xation pictu re arch ivin g an d com m u n ication system posterior cru ciate ligam en t pu lm on ary em bolism positron em ission tom ograph y proxim al in terph alan geal plaster o Paris proxim al ph alan x patella ten don bearin g posterior talo bu lar ligam en t ran dom ized con trolled trials rest, ice, com pression , elevation ran ge o m otion region al pain syn drom e su perior labru m an terior an d posterior tear satu ration o periph eral oxygen tarsom etatarsal u ln ar collateral ligam en t u n raction ated h eparin ven ou s th rom boem bolism proph ylaxis w h ite blood cell cou n t

XI

Table of conte nts

Table of contents

rontmatte r o re

I

Se ction

o rd

Thom as

c no

In t ro d u ct io n

e di

I

is t o r o f ca s t in g—fro m t e p re s e n t d a

Klaus Dre sing, Pete r Trafton

E

II

Klaus Dre sing, Pete r Trafton

Co n t ri u t o rs

3 III

re via t io n s

e gin n in g t o t e

alte r uchinge r

Prin cip le s o f ca s t in g Klaus Dre sing, ran Se ibe rt, os Enge le n

4

T ro m o s is p ro p

la is

55

an Philipp Sch ttrum pf

I 5

Ta le o f co n t e n t s

3

Klaus Dre sing, Pete r Trafton

le d ge m e n t s

Pre fa ce

Principle s of casting

o gis t ics a n d re s o u rce s in t e ca s t ro o m

63

Klaus Dre sing, os Enge le n

II 6

Pro p e r t ie s o f ca s t m a t e ria ls

5

Klaus Dre sing, os Enge le n

So cio e co n o m ic co n s id e ra t io n s Klaus Dre sing, im

XII

Appe ndix

63

In s t ru ct io n s fo r p a t ie n t s

6 33

arrison

u t co m e s a ft e r n o n o p e ra t ive fra ct u re t re a t m e n t— a t in fo rm a t io n ca n e ga in e d fro m e vid e n ce a s e d m e d icin e e ate

anson, Klaus Dre sing

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Table of conte nts

Se ction

uide line s for nonope rative tre atment and periope rative prote ction 3

ra ct u re s , d is lo ca t io n s , a n d s u lu a t io n s o f t e u p p e r e t re m it

Se ction 4

5

ichard Kdols , Cle me ns Dumont

ra ct u re s , d is lo ca t io n s , a n d s u lu a t io n s o f t e lo e r e t re m it No n o p e ra t ive t re a t m e n t o f s p in a l fra ct u re s lorian

4

ve r vie o f ca s t , s p lin t , o r t o s is , a n d a n d a ge t e c n i u e s

5

Klaus Dre sing, os Enge le n

4 35

ami Moshe if, uan Manue l Concha

3

Te chni ue s—casts, splints, and support bandage s 55

ve r vie o f ca s t , s p lin t , o r t o s is , a n d a n d a ge t e c n i u e s — d e m o n s t ra t io n fo rm a t a n d ico n s Klaus Dre sing, os Enge le n

5

e bhard, Pete r ichte r, astian Sche ide re r

Pe d ia t ric fra ct u re s Thomas Ne ubaue r

So ft t is s u e d a m a ge a n d d e fe ct s

5

Cle me ns Dumont

iga m e n t a n d t e n d o n in u rie s

3

Kame l Afifi

Ne r ve in u rie s Endre arga

In d ica t io n s fo r n o n o p e ra t ive t re a t m e n t o f in fe ct io n s

3

Mate Cim e rman

3

ve rlo a d in u rie s

4

Mile s rancis T De la osa

XIII

Table of conte nts

5

p p e r e t re m it

3 5

Klaus Dre sing, os Enge le n

6

46

o e r e t re m it Klaus Dre sing, os Enge le n

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XI

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Table of conte nts

Sp in e

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Klaus Dre sing, os Enge le n

Su p p o r t

a n d a ge s

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X

XI

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

P INCIP ES Principles of Casting

Principles

In t ro d u ct io n la u s re s in g , Pe t e r Tra ft o n is t o r o f ca s t in g—fro m t e a lt e r Bu c in ge r 3 4 5 6

3 e gin n in g t o t e p re s e n t d a

Prin cip le s o f ca s t in g la u s re s in g , ra n Se i e r t , o s

n ge le n

T ro m o s is p ro p la is a n P ilip p Sc t t ru m p f o gis t ics a n d re s o u rce s in t e ca s t ro o m la u s re s in g , o s n ge le n Pro p e r t ie s o f ca s t m a t e ria ls la u s re s in g , o s n ge le n So cio e co n o m ic co n s id e ra t io n s la u s re s in g , im a rris o n u t co m e s a ft e r n o n o p e ra t ive fra ct u re t re a t m e n t— a t in fo rm a t io n ca n e ga in e d fro m e vid e n ce a s e d m e d icin e Be a t e a n s o n , la u s re s in g

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Klaus Dre sing, Pe te r Trafton

Introduction Co n t e n t s a n d s t ru ct u re Principle s of casting uide line s Te chni ue s

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Introduction

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Authors

Klaus Dre sing, Pe te r Trafton

Introduction

Alth ou gh early active m otion is a valid goal or reh abilitation , postoperative extern al im m obilization is o ten still desirable or th e protection o h ealin g tissu es, to preven t con tractu res, an d to assist w ith u n ction al reh abilitation . Ch ildren , w h ose ractu res h eal rapidly an d w h o are ar less likely to develop perm an en tly sti join ts a ter im m obilization , are still u su ally treated w ith casts, even a ter open redu ction . Fin ally, as Ch arles Cou rt-Brow n an d h is colleagu es recen tly reported rom th eir Edin bu rgh trau m a cen ters (h igh ly regarded or su rgical experien ce an d expertise), th e n on operative m an agem en t o ractu res con tin u es to predom in ate. Non operative tech n iqu es w ere ou n d to h ave been u sed or th ree qu arters o th e ractu res th ey h ad treated—tw o th irds o th e adu lts, an d m ore th an 90% o th e ch ildren [1].

e p i n i

Over th e past several decades, an d particu larly sin ce th e ou n din g o th e AO Fou n dation in 1958, th e operative treatm en t o ractu red bon es h as developed an d expan ded rapidly. As th e arts an d scien ces o open redu ction an d in tern al xation h ave f ou rish ed, th e earlier tech n iqu es an d skills o extern al im m obilization h ave le t th e repertoire o trau m a an d orth opedic su rgeon s. Older su rgeon s, n earin g retirem en t, o ten rem ark th at today’s train ees, as w ell as m ost colleagu es train ed in th e last 30 years, are qu ite u n am iliar w ith th e application an d appropriate u se o casts, splin ts, an d su pport ban dages. On e m igh t easily assu m e th at operative xation h as replaced th e u se o su ch tech n iqu es, particu larly or th e treatm en t o u n stable an d displaced ractu res. Bu t is it really correct to con clu de th at extern al im m obilization is n o lon ger a n ecessary part o th e su rgeon ’s skill set, or th at it can be delegated to oth er m em bers o th e m edical care team —n u rses, tech n ologists, or orth otists? Th e au th ors an d editors o th is book stron gly believe th at th e an sw er is “n o”.

In oth er m edical care settin gs, particu larly in developin g h ealth care system s, th e resou rces or operative ractu re care can be qu ite lim ited, an d n on operative tech n iqu es m u st be relied u pon even m ore. Valid ou tcom e m easu rem en ts are th e basis or determ in in g optim al m an agem en t or a given ractu re in a particu lar settin g. Also n ecessary is con sideration o all relevan t patien t ch aracteristics as w ell as th e resou rces an d experien ce o th e treatin g team . Patien t-based ou tcom e m easu res are th e gold stan dard or evalu ation o treatm en t resu lts. As su ch assessm en t tech n iqu es are in creasin gly u sed, th ey occasion ally reveal th at th e resu lts o n on operative care are at least as good as th ose ach ieved w ith operation s, o ten to th e su rprise o su rgeon s an d patien ts th at h ave com e to believe th at su rgery is requ ired or good ou tcom es.

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It is w idely recogn ized th at both tech n ical skill an d appropriate equ ipm en t are im portan t or operative treatm en t. We believe th at th e sam e is tru e or extern al im m obilization u sed or m u scu loskeletal disorders. Th e w ork o Loren z Böh ler, in clu din g h is The Treatment of Fractures, w h ich w as u pdated an d expan ded over m an y decades an d tran slated in to eigh t lan gu ages, clearly sh ow ed h ow im portan t an d e ective plaster cast im m obilization is in th e treatm en t o bon e ractu res [2]. Major con tribu tion s to th e u n derstan din g an d u se o extern al im m obilization w ere provided by m an y oth ers, in clu din g Jean Lu cas-Cam pion n iere an d George Perkin s. Particu larly n otable is Joh n Ch arn ley, w h ose w ork The Closed Treatment of Common Fractures [3] rem ain s a valu able textbook today 64 years a ter its in itial pu blication . Au gu sto Sarm ien to, a Colom bian w orkin g in th e USA, w ith h is en gin eer colleagu e Loren Latta, advan ced th e u se o u n ction al casts an d braces, as w ell as th e u n derstan din g o th e m ech an ics o extern al im m obilization .

5

Introduction

Su pportive im m obilization is an essen tial com pon en t o prim ary care or u n stable an d pain u l skeletal in ju ries. In addition to n on operative treatm en t, it is o ten u sed perioperatively in both trau m a treatm en t an d recon stru ctive su rgery, as w ell as or th e care o w ou n ds or in ection s. Th u s, kn ow ledge o m aterials an d tech n iqu es or casts, splin ts, an d su pport ban dages rem ain s im portan t in today’s trau m a an d orth opedic su rgery.

Co n t e n t s a n d s t ru ct u re

Th e book com prises th ree section s: • Prin ciples o castin g • Gu idelin es or n on operative treatm en t an d perioperative protection • Tech n iqu es o casts, splin ts, an d su pport ban dages.

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Fu rth erm ore, th e prescription an d application o th ese devices m u st rem ain th e su rgeon ’s respon sibility. A poorly plan n ed or poorly applied cast m ay n ot provide th e n eeded im m obilization . It can also resu lt in com plication s w ith poten tial perm an en t h arm stem m in g rom pressu re sores, n erve palsies, con tractu res, or com partm en t syn drom e. Even w h en th e actu al application o a cast or oth er su pportin g ban dage is delegated, th e su rgeon m u st be able to plan appropriately an d to evalu ate th e applied device, to recogn ize w h en it is satis actory, an d w h en it m u st be revised. Tim e an d in n ovation h ave brou gh t ch an ges to m aterials an d tech n iqu es or extern al im m obilization . Today, m in eral plaster o Paris casts an d splin ts h ave been partly replaced by casts, splin ts, an d orth oses m ade o syn th etic m aterial. Th ese are typically ligh ter, m ore com ortable, an d accom m odate im proved u n ction . Rigidity can be ch osen or an optim al balan ce betw een su pport an d u n ction al u se. In creased du rability, w ater resistan ce, an d in som e cases, th e ability to be rem oved by th e patien t or am ily, are also available option s.

Th e rst section , Prin ciples o castin g, presen ts basic in orm ation abou t extern al im m obilization . Ch apters 2 an d 6 ch art th e progress rom early plaster casts to today‘s variety o m aterials or su ch dressin gs: m odern plaster o Paris, rigid syn th etics, an d also m ore com plian t syn th etics or sem irigid casts, so-called so t casts. Ch apter 3 explores th e key prin ciples o castin g, in clu din g th e prin ciples o bon e h ealin g, types o splin ts an d casts, redu ction an d stabilization , an d respon din g to bon e m alalign m en t w ith cast w edgin g. Ch apter 4 discu sses th rom boem bolic risks related to in ju ries an d im m obilization , an d review s proph ylaxis. Ch apter 5 provides a detailed overview o th e resou rces, equ ipm en t, ligh tin g an d electrical su pply, an d sta n g n eeded to ru n a sa e an d w ell stocked m odern day cast room . Logistical an d econ om ic issu es are review ed in ch apter 7, recogn izin g tech n ical issu es an d th e di eren ces betw een m ore an d less-developed h ealth care system s. Fin ally, ch apter 8 con siders eviden ce-based ou tcom es rom n on operative treatm en t, dem on stratin g its im portan ce or th e care o appropriately selected in ju ries. u id e lin e s

Casts, Splints, and Support Bandages— Nonoperative Treatment and Perioperative Protection h as been created as a com preh en sive re eren ce or th e im m obilization o an exten sive ran ge o m u scu loskeletal disorders. It is in ten ded or su rgeon s, as w ell as oth er m em bers o th e treatin g team , particu larly n u rses an d orth opedic tech n ologists, an d stu den ts preparin g or th ese pro ession s. It provides an exten sive overview o th e h istory, prin ciples, m eth ods, an d tech n iqu es or applyin g a plaster or syn th etic cast, or n on operative care as w ell as perioperatively.

6

Th e secon d section , Gu idelin es, com prises ch apters th at explore speci c n on operative treatm en t or ractu res, ligam en t, n erve, an d so t-tissu e in ju ries, overload in ju ries, an d in ection s, in th e u pper an d low er extrem ities an d th e spin e, an d in pediatric patien ts. A com preh en sive approach is presen ted to h elp th e reader u n derstan d th e in dication s an d plan appropriate im m obilization or optim al patien t ben e t.

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

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1. Co u r t Bro n C , it e n S, a m ilt o n T , e t a l . Non operative ractu re treatm en t in th e m odern era. J Trauma. 2010 Sep; 69(3):699 –707. 2. B le r . The Treatment of Fractures. 4th ed En glish . Baltim ore: William Wood an d Com pan y; 1936. Altern atively: B le r . Die Technik der Knochenbruchbehandlung. 13th ed. Vien n a: Verlag Wilh em Mau d rich ; 1996. Germ an . 3. C a rn le . The Closed Treatment of Common Fractures. 4th ed. Un ited Kin gdom . Cam bridge Un iversity Press; 2010.

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Th e book does n ot presen t a sin gle com preh en sive view o prim arily n on operative ractu re treatm en t, in th e m an n er o Loren z Böh ler. Ou r w orld-w ide grou p o au th ors, m em bers o AOTrau m a, h ave all con tribu ted th eir in dividu al view poin ts, based on person al experien ce an d practices. Wh ile each is an expert in su rgical trau m a care, th ey all recogn ize th e im portan ce o n on operative im m obilization as a prim ary treatm en t, an d as an adju n ct to su rgery. An o ten -repeated joke is th at “AO stan ds or Alw ays Operate” bu t th is text presen ts a m ore eclectic vision o trau m a care. All f ve geograph ic region s o AOTrau m a are represen ted

Th e editors an d au th ors are aw are th at som e in dication s or presen ted tech n iqu es m ay be u n am iliar, an d th at altern ative care regim en s an d tech n iqu es are abu n dan t. We h ave n ot attem pted to presen t or discu ss th e w ide variety o available orth oses, eith er m ass produ ced or cu stom -m ade by an orth otist, as to do so w ou ld h ave exceeded th e book’s scope. We ch ose in stead to illu strate th e prin ciples o im m obilization an d su pport w ith tech n iqu es th at u se m aterials available in th e typical su rgical cast room . In deed, w e h ope th at w h at w e h ave selected w ill provide valu able gu idan ce or e ective practice an d u rth er advan cem en t o trau m a care. We are con f den t th at th is AOTrau m a book Casts, Splints, and Support Bandages— Nonoperative Treatment and Perioperative Protection w ill h elp im prove patien t care arou n d th e w orld.

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Fin ally, th e th ird section called Tech n iqu es provides stepby-step description s o 55 in dividu al castin g, splin tin g, orth otic, an d ban dagin g tech n iqu es, presen ted in tw o w ays. In th e prin ted book, th e dem on stration s com prise still ph otograph s an d illu stration s w ith explan atory text. How ever, th e reader can also review each o th e 55 im m obilization dem on stration s in h igh -qu ality video, by u sin g th e access code on th e in side cover o th e book an d visitin g th e Th iem e Media Cen ter w ebsite.

am on g th e au th ors. It w as a great h on or th at each o th e au th ors im m ediately accepted th e editors' in vitation to con tribu te rom th eir great experien ce in n on operative an d operative trau m a su rgery. Th e resu lt is th is n ew AOTrau m a book, w h ich presen ts a vitally im portan t, bu t cu rren tly poorly docu m en ted, part o ou r care or in ju red patien ts.

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Introduction

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

alte r E uchinger

istor of casting—from the beginning to the present da alte r E uchinge r

In t ro d u ct io n e

irs t fin d in gs

o m a n e ra

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T e t t ce n t u rie s Nonope rative tre atm e nt and the re at ar M lle r and the AO or ing roup Plastics, s nthe tic, and close d functional fracture tre atm e nt Su m m a r e fe re n ce s

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Author

alte r E uchinger

Pre C ris t ia n e ra

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In th e an alysis o preh istoric skeleton s an d w ell-preserved Egyptian m u m m ies, it w as discovered th at, even in an cien t tim es, som e kin d o treatm en t or ractu res by m ean s o splin tin g an d dressin g w as per orm ed. In th e Edwin Smith Papyrus, an an cien t Egyptian scroll kn ow n as th e w orld’s “oldest su rgical textbook” (datin g back to th e 17th cen tu ry BC), th ere are speci c re eren ces to ractu re treatm en t [1, 2]. Even today, in som e parts o Asia, Sou th Am erica, an d A rica, “bon esetters” provide treatm en t based on an cien t m agic spells an d oin tm en ts in con ju n ction w ith splin ts m ade rom cardboard or plyw ood (bam boo poles in Ch in a) or th e pu rpose o ractu re im m obilization [3].

ig Through Ol m pic wre stling bouts and hand to hand com bat, the ancie nt re e s le arne d that the full we ight of an oppone nt, or a dire ct blow to an unprote cte d lim b, could e asil cause sprain or fracture

Th e m ost am ou s n am e o th is era is, n o dou bt, Hippocrates (460–370 BC). Th e Hippocratic Corpus, pu blish ed in several volu m es, lists exact in stru ction s pertain in g to th e treatm en t o ractu res [4]. It in clu des detailed in orm ation on ractu re treatm en t, an d describes h ow ban dages w ere sti en ed by applyin g a m ixtu re o w ax an d resin , on top o w h ich splin ts rom w ood or iron w ere placed. It also provides xation tim es or th e m ost com m on types o ractu re, an d describes a kin d o extern al xator or th e treatm en t o low er-leg ractu res com posed o rin gs placed on th e kn ee an d an kle join ts, an d con n ected by rods ( ig ) [5, 6]. It is u n clear h ow m u ch o th e com plete w ork can be attribu ted to Hippocrates h im sel du e to di eren t dates o pu blication s an d varyin g qu ality o th e text—som etim es th e text even con tradicts itsel . Neverth eless, h is th eories provided great in sigh t in to early m edicin e an d ractu re treatm en t.

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In an cien t Greece, n u m erou s w ars took place am on g th e Greek city states, an d oth er grou ps, du rin g th e secon d preCh ristian m illen n iu m . Addition ally, th ou gh glori ed today as a m ean s o peace u l com petition , th e an cien t Olym pic Gam es in clu ded extrem ely bru tal gh tin g an d w restlin g even ts ( ig ). Victory m ean t great prestige to th e gh ter as w ell as to h is region o origin , bu t th e resu ltin g in ju ries to th e loser (or w in n er) created a n eed or su itable “treatm en t cen ters”. Th u s, a large n u m ber o m edical sch ools w ere ou n ded.

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From ou r earliest existen ce, h u m an s h ave ou n d in n u m erable w ays to in ju re th e bon es an d su pportin g stru ctu res o ou r ragile skeletal system . Yet, over tim e, w e h ave also slow ly developed a greater u n derstan din g o th e w orkin gs o th e h u m an body. Today, h igh ly train ed su rgeon s an d oth er m edical pro ession als u se in credible skill, operative an d n on operative tech n iqu es, an d state o art in stru m en ts to repair even th e m ost dam aged bon es an d extrem ities. So, be ore w e explore th e u n derlyin g prin ciples o m odern castin g, it is im portan t to rst ou tlin e th e critical m om en ts an d h istorical gu res th at h elped brin g th e kn ow ledge o castin g to w h ere it is today.

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Follow in g th e ou n dation o Alexan der th e Great’s em pire, th e cen ter o m edical scien ce m oved rom th e Greek m oth erlan d to th e capital Alexan dria, n ew ly establish ed in 331 BC, w ith its am ou s library th at, am on g its 700,000 scrolls, also con tain ed th e Hippocratic Corpu s.

experien ced m ajor im provem en ts. Rh azes Ath u riscu s (865– 925) ( ig 4 ), or exam ple, recom m en ded th e u se o cloth satu rated w ith lim e or plaster, w h ich h eld th e lim b rm , as w as ou n d to be e ective or th e xation o bon e ractu res.

Th e con qu est by Au gu stu s an d th e in corporation o Egypt as a Rom an protectorate in trodu ced Greek scien ces, an d th u s m edicin e, to th e Rom an Em pire. For a lon g tim e, Alexan dria, as th e secon d largest city o th e Rom an Em pire, rem ain ed its cu ltu ral an d in tellectu al cen ter an d Greek doctors, u su ally train ed in Alexan dria, w ere h igh ly sou gh t specialists.

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In regards to th e treatm en t o in ju ries in early m edicin e, on e n am e rem ain s ou tstan din g, Galen o Pergam on , w h o w as ren ow n ed or treatin g gladiators ( ig 3 ). He lived an d w orked in Rom e in th e 2n d cen tu ry AD. In h is w ork De Ossibus ad Tirones, w h ich reely tran slates in to “Abou t bon es or begin n ers”, h e described an d re n ed th e m eth ods listed in th e Hippocratic Corpu s [8].

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On ce th e Greek an d Rom an em pires h ad been destroyed, th e practice an d stu dy o m edicin e in Eu rope w as lim ited to religiou s m on asteries. Sin ce th e ch u rch disapproved o all pagan ritu als an d practices (an d th is in clu ded th e h igh ly developed Arabic m edicin e), m edical progress in Eu rope stagn ated. Recogn ition o th e valu e o Arabic m edicin e (as w ell as its Greek an d Rom an origin s) m oved on ly slow ly. On e o th e last clerical doctors w as Gu y de Ch au liac (Ch au lh iaco) (1300–1368), w h o in h is w orks Chirurgia Magna described in great detail im m obilizin g ban dagin g tech n iqu es (listin g m aterials su ch as w ood, leath er, iron , an d h orn , already m en tion ed in Arabic an d Greek texts) an d also recom m en ded th e u se o steady traction (exten sion ) over a cylin der in order to avoid bon e sh orten in g [9].

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With th e expan sion o th e Arabic/ Islam ic w orld in th e secon d h al o th e rst m illen iu m AD, a n ew em pire em erged, exten din g rom th e Him alayas to th e Pyren ees. Based on Greek an d Rom an prin ciples, th e Arabic m edical practition ers developed n ew in sigh ts, an d th e art o m edical h ealin g

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From th e 13th cen tu ry, th e career opportu n ities o clerical doctors w ere severely redu ced by a ch u rch re orm ation . It h as been argu ed th at on e o th e triggers or th is crack dow n on th e practice o m edicin e w as th at som e practition ers w ere applyin g m edicin e or th eir ow n ben e t rath er th an th e patien t’s w ell-bein g. Th e eld o m odern su rgery sh ares a som ew h at sim ilar h istory.

ig 3 ale n of Pe rgam on e xplore d wa s to tre at bone fracture s following gladiatorial conte sts with swords, clubs, and e ve n spi e d iron balls

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

alte r E uchinger

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Du rin g th e 17th an d 18th cen tu ries, n u m erou s textbooks on trau m a su rgery w ere pu blish ed. Th eir au th ors, Du vern ey, Petit, Larrey, Heister, Sch u ltes, Desau lt, Malgaign e (also w ith ou t u n iversity train in g), Pott, Jon es, Sm ith , w ere all w ell-kn ow n an d are still recogn ized today. Statistical rew orkin g an d ollow -u p exam in ation s w ere in trodu ced, an d con clu sion s regardin g diagn osis an d th erapy w ere draw n rom au topsy resu lts.

ig 4 ha e s Athuriscus use d cloth saturate d with lim e or plaste r for the xation of bone fracture s

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Even tu ally, su rgery began to be w ell-practiced by som e o th ese cra tsm en , as dem on strated by th e barber su rgeon Am broise Paré, w h o received little i an y u n iversity train in g. He w orked at a tim e w h en in ju ries cau sed by rearm s w ere con sidered to be poison ou s an d h ad to be cau terized by h eated iron or scaldin g h ot oil. Du rin g th e Fren ch cam paign s o th e 16th cen tu ry (w h en oil h ad becom e scarce), Paré realized th at a m ixtu re o essen ce o rose, egg yolk, an d tu rpen tin e sh ow ed better resu lts [10]. In peace tim es, h e ocu sed on th e prim ary description o ractu res o th e em oral n eck, am on g oth er activities.

In 1792, Jean Dom in iqu e Larrey (Napoleon ’s person al ph ysician an d later, su rgeon -in -ch ie or th e en tire Napoleon ic Arm y) ( ig 5 ) in ven ted th e albu m en dressin g, w h ich took tw o days to com pletely dry. How ever, becau se o th is delay (an d its th ick paddin g) it provided en ou gh elasticity to allow room or th e in itial sw ellin g th at u su ally occu rs a ter ractu re in ju ries. Th is particu lar dressin g cou ld be le t on u n til th e ractu re h ad h ealed an d, u n like Hippocrates’ version , did n ot requ ire requ en t ch an gin g, w h ich at th e tim e w as h igh in cost an d m aterial. How ever, even th ou gh th e n ew dressin g w as su perior in term s o sti n ess to th e previou s splin ts m ade rom w ood, leath er, etc, th e lon ger dryin g tim e an d h igh dem an d on raw m aterials w ere still con sidered a disadvan tage. For each low er-leg ractu re, 50–70 eggs w ere n eeded. It is likely th at th is h igh dem an d w ou ld h ave posed a sign i can t ch allen ge or th e su pply o cers in th e Napoleon ic arm y, even th ou gh strin gen t pressu re w as im posed on th e ru ral popu lation o an y occu pied territories [11].

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In itially, m oderately com plex su rgery w as practiced by barber su rgeon s an d “qu ack” doctors—w h en in act th e w ord su rgery in its tran slation rom Greek m ean s cra tsm an or “w orkin g w ith on e’s h an ds”. At oth er tim es, it w as tau gh t on an academ ic level. Despite th is, th e era or critical scru tin y an d qu estion in g o tradition al th in kin g h ad begu n . As an exam ple, in th e 16th cen tu ry, An dreas Vesaliu s (1514– 1564) w as able to correct large parts o Galen ’s teach in gs th rou gh n din gs h e gath ered rom h u m an au topsies.

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At th at tim e, plaster w as also already u sed in th e orm o th e plaster m old, in w h ich th e extrem ity in qu estion w as placed in a case, an d plaster was th en m olded arou n d it u n til 2/ 3 o th e respective lim b w as covered. Th e poten tial disadvan tages o th is m eth od in clu ded h eat dam age, skin m aceration , an d, ju st as with Larrey’s dressin g, an obligatory len gth y bed rest. Most likely, th e procedu re or takin g o th e cast w ith h am m er an d ch isel w ou ld n ot h ave con tribu ted m u ch to a tru st u l relation sh ip betw een doctor an d patien t [8].

ig 5 e an Dom ini ue arre —Napole on s pe rsonal ph sician Painting b Anne ouis irode t De ouss Trioson MN rand Palais Mus e du ouvre Thie rr e Mage

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Th e 19th cen tu ry rst brou gh t an in n ovation im petu s or im m obilizin g dressin gs, ollow ed by advan ces in gen eral su rgery. Stability o th e Larrey dressin g w as in creased in th e rst h al o th e cen tu ry by th e Belgian gen eral practition er LJ Seu tin (1793–1862) as h e u sed glu e m ade rom f ou r to im pregn ate th e dressin g. Splittin g th e cast w as obligatory, as w ell as en estration in th e case o open ractu res. A ter redu ction o th e sw ellin g, th e ban dagin g w as closed or adapted by cu ttin g ou t parts as n eeded. For th e rst tim e, th is kin d o treatm en t cou ld even be accom plish ed on an ou t-patien t basis [12].

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In th e secon d h al o th e 19th cen tu ry, An ton iu s Math ijsen (1805–1878) ( ig 6 ), a Du tch n avy su rgeon , optim ized ractu re treatm en t by in trodu cin g cotton soaked w ith plaster o Paris [13]. He is gen erally con sidered to be th e in ven -

tor o th e plaster cast, h ow ever, at th e sam e tim e, Ru ssian su rgeon Nikolai Pirogo (1810–1881) described th e sam e kin d o tech n iqu e, w h ich h e u sed du rin g th e Crim ean w ar [14]. Arou n d th e sam e tim e, a n u m ber o n ew in ven tion s com pletely ch an ged th e su rgical rou tin e. Kn ow ledge o pain m an agem en t an d an esth esia w ere tran s erred rom Am erica to Eu rope, th e im portan ce o an tisepsis (Sem m elw eis, Lister, Friedrich ) becam e eviden t, an d th e in ven tion o x-ray tech n ology en abled th e prem ortem an alysis o ractu res. At th at tim e, on ly 10% o all in ju red patien ts w ith open ractu res kept th eir lim bs; 50% died, an d 40% h ad to en du re am pu tation ( ig . Moreover, th e m ortality rate o prim ary am pu tation s w as abou t 75% [15]. In appropriate application o th e n ow sti dressin g in itially led to a n u m ber o com plication s, su ch as decu bitu s, circu -

ig 6 Antonius Mathi se n, who is ge ne rall conside re d as the inve ntor of the plaste r cast Monum e nt at his birthplace , ude l, in The Ne the rlands

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

alte r E uchinger

m an n Nagel” (Stein m an n Pin ), coin ed by th e Sw iss su rgeon Fritz Stein m an n , is w ell kn ow n [17]. Sin ce pen etratin g th e cortex w ith a n ail m igh t cau se ssu res, in 1927 Martin Kirsch n er su ggested drillin g in a w ire in stead, a m eth od w h ich h as becom e w ide-spread [18].

Slim plaster w ith ou t th e h eavy paddin g allow ed better assessm en t o th e position o th e axis. Th e tech n iqu e o in clu din g th e n eigh borin g join ts w ith in th e xation , w h ich h ad been practiced sin ce th e 18th cen tu ry, proved to be u se u l in avoidin g m alrotation . How ever, it w as n ot su itable to avoid sh orten in g in th e case o low er-extrem ity ractu res. Th e earlier m eth ods applied or exten sion treatm en t w ere u n su itable, as traction w as attach ed directly to th e skin via loops or ban dages, w h ich resu lted in lesion s o th e skin , th e perin eu m , or axilla cau sed by th e n ecessary cou n terstrain .

As alw ays, it took a w h ile be ore experien ce w ith n ew tech n iqu es overcam e in itial ailu res (h ypercorrection du e to too m u ch w eigh t, resu ltin g in problem s w ith so t tissu es an d n on u n ion , in appropriate exten sion tim es, etc).

In later years, Percival Pott poin ted ou t th at relaxation o th e leg m u scles by ben din g h ip an d kn ee join ts m igh t resu lt in a distin ct decrease o th e requ ired w eigh t, n eeded to avoid bon e sh orten in g. Th is w as w ell em ployed by Robert Ch essh er, w h o in trodu ced a dou ble-in clin ed ram e. FH Ham ilton cam e u p w ith a sim ple solu tion or th e problem o th e cou n terstrain —h e elevated th e oot en d o th e bed [16]. Problem s w ere n ally solved by attach in g traction devices directly to th e bon e. In th e Germ an -speakin g cou n tries, th e term “Stein -

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latory distu rban ce, con tractu res, an d n ecrosis. Lack o experien ce regardin g th e du ration o xation an d w eigh t bearin g as w ell as th e im portan ce o exercisin g th e im m obilized extrem ity—extrem e rest w as recom m en ded—resu lted in n on u n ion , m u scu lar atroph y, an d/ or join t sti n ess.

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On e n am e closely con n ected w ith per ectin g n on operative tech n iqu es is Loren z Böh ler (1885–1973) ( ig ). Wh ile w orkin g in a m ilitary h ospital abou t 30 km rom th e river Ison zo, du rin g World War I, h e gain ed a lot o experien ce u sin g im m obilizin g dressin gs an d traction , applied eith er alon e or in com bin ation . Fu rth erm ore, h e m eticu lou sly kept m edical records an d docu m en ted resu lts an d presen ted th em to th e board o th e com pen satin g in su ran ce body in Au stria a ter th e w ar. It w as discovered th at th e com pen sation paid by th e Arbeiteru n allversich eru n g (AUVA) or w orker’s com pen sation a ter an in du strial acciden t w as m u ch larger th an or a com parable w ar in ju ry th at h ad been treated accordin g to Böh ler’s prin ciples. Th is m ade h is tech n iqu es qu ite con vin cin g.

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ig Throughout histor , much m e dical nowle dge was ac uire d on the battle e ld ntil the discove rie s m ade b wartim e surge ons such as arre , Mathi se n, and Pirogoff, ope n fracture s from gunshot wounds or shrapne l we re re gularl tre ate d with am putation

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In 1925, th e rst trau m a h ospital o th e AUVA w as ou n ded, w ith a total capacity o 52 beds. With in on e year, Böh ler w as able to prove th at th e am ou n t saved on com pen sation exceeded th e ru n n in g costs. Over th e years, th e th in script w ritten or h is stu den ts evolved in to a ou r-volu m e re eren ce book called The Treatment o Fractures, w h ich h ad been pu blish ed, w ith m u ltiple edition s, in Germ an an d eigh t oth er lan gu ages (in clu din g Ch in ese) by 1970. Every m an eu ver in ractu re redu ction an d im m obilization w as described in great detail, in clu din g tim e ram es or im m obilization as w ell as th e con sequ en ces o n ot adh erin g to th e given gu idelin es [19]. Th e su ccess u l “Böh ler’s sch ool” w as based on th ree pillars: • Stan dardized gu idelin es or n on operative tech n iqu es, w h ich h ad to be strictly adh ered to • Strict organ ization , an d • Th e possibility to treat an d observe patien ts rom day 1 u n til u ll recu peration an d th eir retu rn to w ork. “Fractu re redu ction , im m obilization , train in g” w ere h is gu idin g prin ciples. Traction h ad to be ch ecked tw ice a day an d plaster dressin gs w ere on ly allow ed w ith ou t paddin g as th is en su red th at th e redu ced ractu res w ere kept in th e correct position . Th is o cou rse w as on ly possible by con stan t an d organ ized observation an d ollow -u p treatm en t. I n eeded, in case o pain or sw ellin g, im m ediate action su ch as en estration , splittin g, or reapplication o th e dressin g h ad to be carried ou t. All im m obilized patien ts h ad to participate in special program s o ph ysical th erapy an d, th u s, m u scu lar atroph y an d join t sti en in g (th e so-called “cast disease”) cou ld be avoided. Th ou gh Böh ler, as w ell as h is su ccessors,

ig ore n hle r, author of the four volum e re fe re nce wor Te chni ue s of racture Tre atm e nt during a critical re vie w of a tre at m e nt outcom e

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pu blish ed an extrem ely large n u m ber o treated cases (m ore th an even in cu m u lative stu dies today) w ith excellen t ollow u p resu lts, th ese reports w ere aston ish in gly still u n der discu ssion by recen t au th ors. With th e in trodu ction o an esth esia an d asepsis, th e n u m ber o seriou s e orts or treatin g bon e ractu res su rgically in creased (Berard, Lam botte, Lan e, Han sm an n , Hey Groves, an d oth ers). How ever, su rgical in su cien cies o th e tech n iqu es applied at th at tim e cou ld n ow be dem on strated exactly by radiology, w h ich h ad becom e gen erally available. Th u s, m an y su rgeon s in itially disapproved o osteosyn th esis or regarded it as an ‘u ltim a ratio’ salvage procedu re. lle r a n d t e

o r in g

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Th e break-th rou gh n ally cam e w ith system atic research in m etallu rgy, biom ech an ics, an d bon e h ealin g u n der con dition s o osteosyn th esis. Th is w as in itiated by th e Sw iss ME Mü ller (1918–2009), w h o, in con ju n ction w ith n otable su rgeon s an d a m an u actu rer o su rgical in stru m en ts, ou n ded th e “w orkin g grou p on qu estion s related to osteosyn th esis” (Arbeitsgem ein sch a t ü r Osteosyn th ese), n ow th e AO Fou n dation , in 1958. A n ew era o ractu re treatm en t began an d tim es started to ch an ge as n on operative treatm en t m easu res su bsided gradu ally. How ever, th ere w as n o m u tu al u n derstan din g am on g ollow ers o th e n on operative treatm en t an d th ose o th e su rgical treatm en t ph ilosoph y. Perh aps th is w as du e to th e act th at experien ce w ith n on operative tech n iqu es ou tside Böh ler’s sph ere o in f u en ce w as n ot w ell establish ed. In th e 1950’s, th e am ou n t o com pen sation th e Sw iss in su ran ce com pan y (SUVA) paid or em oral ractu res w as ou r tim es h igh er th an th at paid in Au stria, th e am ou n t or low er-leg ractu res w as 10 tim es h igh er [6]. Bu t even tu ally, even th e m ost erven t advocates o n on operative tech n iqu es h ad to accept th at osteosyn th esis provided an essen tial advan tage com pared w ith n on operative treatm en t, even i th e ach ieved resu lts w ith both m eth ods w ere com parable, becau se th e patien t’s com ort im proved. Non operative m eth ods soon lost popu larity an d becam e an ou tside option ; today, on ly a lim ited n u m ber o em ergen cy departm en ts actu ally kn ow h ow to apply th ese m eth ods. Th is seem s to be an u n ortu n ate developm en t becau se: • Th ere are patien ts w h ose gen eral con dition or pattern o in ju ry do n ot allow su rgical in terven tion ; in su cien t kn ow ledge o n on operative m eth ods w ill resu lt in u n satis actory resu lts, w h ich are u su ally attribu ted to th e m eth od rath er th an to th e in correctly applied tech n iqu e— du e to its n ot bein g com m on an ym ore

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

alte r E uchinger

In th e 1970s, oth er types o syn th etic cast m aterials w ere in trodu ced to ractu re care. At rst, berglass textile abrics im pregn ated w ith a ligh t-activated resin w ere u sed. Th e stability o th e cast w as in du ced by exposu re to u ltra-violet ligh t. In th e late 1970s, w ater-activated syn th etic cast m aterial w as u sed or th e rst tim e. Today, kn itted abrics o polyester, berglass, an d berglass- ree polym er m aterials are in u se, w h ich are im pregn ated w ith polyu reth an e or resin s o polyu reth an e. Water exposu re accelerates th e polym erization an d th e h arden in g process. Correspon din g to th e m aterial com position , th e resu lts vary rom rigid to sem irigid casts. In 1981, Sarm ien to an d Latta in trodu ced “closed u n ction al ractu re treatm en t”. Th is m eth od in volves a brace coverin g on ly th e broken bon e, th u s preven tin g lateral givin g-w ay o th e su rrou n din g so t-tissu e an d, at th e sam e tim e, it u n ction s as a pu lley ten sion belt th at also spreads th e pressu re over th e en tire ractu red area [20]. Com pared to Böh ler’s m eth od, axis distortion an d sh orten in g are m ore requ en t, th ere ore, application in variou s body region s (eg, in th e case o low er-leg ractu res) sh ou ld be h an dled w ith cau tion . Addition ally, it is n ecessary to ch eck an d adju st th e brace requ en tly accordin g to th e am ou n t o sw ellin g o th e so t-tissu e. Th e last exten sive description o n on operative ractu re treatm en t w as don e by on e o Böh ler’s stu den ts, H Jah n a (1920– 2003). In 1985, togeth er w ith H Wittich , h e pu blish ed Conservative Methods in Bone Fracture Treatment [21]. Even today, h is w ork is con sidered h igh ly m eticu lou s an d exem plary in term s o redu ction tech n iqu es an d u se o m aterials. It also in clu des a large ch apter on h ow to produ ce im m obi-

Su m m a r

• Th e u n iqu e properties o plaster h ave been kn ow n sin ce an cien t tim es, yet th e earliest orm s o casts an d splin ts com prised su ch m aterials as w ood, leath er, w ax, or eggs • Hippocrates o Greece developed a set o in stru ction s or ractu re treatm en t, an d u rth er kn ow ledge w as developed du rin g Rom an , an d later, Arabic periods • In th e 1800s, w artim e su rgeon s su ch as Larrey, Math ijsen , an d Pirogo u sed plaster casts to treat open w ou n d ractu res, w h ich dram atically im proved th e ch an ces o su rvival or both lim b an d patien t • From h is experien ces in th e First World War, Böh ler pu blish ed a 4-volu m e set on ractu re treatm en t; h e is con sidered a ou n din g ath er o m odern castin g • More recen tly, plastics an d ligh ter syn th etic m aterials w ere developed or castin g, an d th e Sarm ien to tech n iqu e o u n ction al treatm en t w as in trodu ced, u sin g braces, w h ich allow s th e lim b som e m ovem en t to redu ce m u scle breakdow n du rin g im m obilization .

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Du rin g th e 1950s, casts m ade rom plastic rst m ade th eir appearan ce. In th e begin n in g, th eir h an dlin g w as qu ite com plicated, som e requ irin g very h igh tem peratu res or UV ligh ts or h arden in g. Th ey w ere also n ot as com ortable to w ear as th ose w ith th e w ater proo , ligh tw eigh t berglass or polyester m aterials u sed today.

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Pla s t ics , s n t e t ic , a n d clo s e d fu n ct io n a l fra ct u re t re a t m e n t

In 1916, Hey Groves poin ted ou t th at a trau m atologist/ orth opedic su rgeon sh ou ld be able to carry ou t n on operative treatm en t ju st as skill u lly as i it w as a su rgical procedu re [22]. It w ou ld be w on der u l to in ally ach ieve th is dem an d in a ield o expertise n early 100 years a ter it w as irst developed.

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lizin g dressin gs on on e’s ow n . Un ortu n ately, w h at is m issin g is a critical review o certain m eth ods m en tion ed on ly or th e sake o com pleten ess. Som e m eth ods w ere already regarded as ou tdated by th e au th ors. Exactly th is w as picked u p by critics o th e book; th e baselin e stu dy an d stan dardizin g o n on operative treatm en t option s in ten ded by au th ors w as n ot u lly appreciated everyw h ere.

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• Th ere are cou n tries in w h ich , du e to in rastru ctu ral decien cies, kn ow ledge tran s er o n on operative tech n iqu es rath er th an su rgical tech n iqu es is m ore advan tageou s • Th ere are cu rren t operative tech n iqu es th at su rely w ou ld ben e t rom kn ow ledge o ractu re-redu ction m an eu vers o th e n on operative “old sch ool”, as can be dem on strated, eg, or th e m in im ally in vasive plate-osteo syn th esis tech n iqu e.

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. [Con tribu tion s to preh istoric su rgery (Paleosu rger y)]. Dtsch Zschr Chir. 1909; 102:109 –140. Germ an . 2. e e r o f . [Abou t Papyru s Edw in Sm ith —th e world’s oldest su rger y book]. Dtsch Zschr Chir. 1931; 231:645 – 690. Germ an . 3. N a c u u B , e s ili IC, a rris B, e t a l . Tradition al bon esetters an d con tem porar y orth opaed ic ractu re care in a developin g n ation : h istor ical aspects, con tem porary statu s an d u tu re d irection s. Open Orthop J. 2011 Jan ; 5:20 –26. 4. d a m s . Th e Hippocratic Cor pu s (tran slation ). The Internet Classics Archive; 1994 –2009. h ttp://classics.m it.edu / Brow se/ brow se-Hippocrates.h tm l. [Accessed Nov 2012]. 5. Sige ris t . [The Beginnings o Medicine: rom Primitive and Archaic Medicine until the Golden Age in Greece]. Zü rich : Eu ropa-Verlag. 1963. Germ an . 6. Po va c . [The History o Trauma Surgery]. 2n d ed. Berlin Heid lberg New York: Sprin ger Verlag; 2007. Germ an . 7. Bic . Sourcebook o Orthopaedics. 2n d ed. Baltim ore: Th e William s & Wilkin s Com pan y; 194 8. 8. u llm a n n , lt o ff , s p e r eds . [Categories o Scientif c Literature in the Ancient World]. Tü bin gen : Gu n ter Narr Verlag; 1998. Germ an . ge r

9. d e C a u l ia co . In ven tariu m Sive Ch iru rgia Magn a. McVau gh M R, Ogden MS (eds). Studies in Ancient Medicine. Vol 1. Leiden , New York: EJ Brill; 1997. 10. a m B. Ambroise Paré (1510–1590) Surgeon o the Renaissance. St Lou is: W H Green ; 1967. 11. o rn d a s c . [Napoleon’s Surgeon: The Li e o Jean Dominique Larrey]. 2n d ed. Bon n : Karl Glöck n er Verlag; 1949. Germ an . 12. Se u t in . [ Essay on th e m eth od o n on -rem ovability-rem ovability o a cast]. Mémoire de l’Académie Royale de Médicine. 1st ed. Bru ssels; 1835. Fren ch . 13. a t i s e n . [Gypsum Dressing]. Cre eld: Kü h ler Verlag; 1857. Germ an . 14. Piro go ff N . [Basic Principles o General Military Surgery]. 1st ed. Leipzig: Vogel Verlag; 1864. Germ an . 15. a lga ign e B. [Treatment o Fractures and Luxations]. Paris: Bailliere; 18 47. Fren ch . 16. a m ilt o n . A Practical Treatise on Fractures and Dislocations. 1st ed. Ph iladelph ia: Blan ch ard an d Lea; 1860. 17. St e in m a n n e d . [ Nail exten sion o bon e ractu res]. New German Surgery. Vol 1. 1st ed. Stu ttgart: En ke Verlag; 1912. Germ an . 18. irs c n e r . [ Im provem en t o w ire exten sion s (Kirsch n er-w ire)]. Arch klin Chir. 1927; 14 8:651–657. Germ an .

19. B le r . [The Treatment o Fractures]. 1st ed. Wien : Wilh elm Mau drich ; 1929. Germ an . 20. Sa rm ie n t o , a t t a . Closed Functional Treatment o Fractures. 1st ed. Berlin Heidelberg New York: Sprin ger-Verlag; 1981. 21. a n a , it t ic . [Conservative Methods in Bone Fracture Treatment]. 1st ed. Wien , Mü n ch en , Baltim ore: Urban & Sch warzen berg; 1985. Germ an . 22. e ro ve s . On Modern Methods o Treating Fractures. 1st ed. Bristol: Joh n Wrigh t & Son s Ltd; 1916.

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, ran Se ibe rt, os Engele n

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Principles of casting Klaus Dre sing, ran Se ibe rt, os Enge len

In t ro d u ct io n

Klaus Dre sing, ran Se ibe rt, os Enge le n

Prin cip le s o f o n e e a lin g Dire ct bone he aling Indire ct bone he aling actors influe ncing norm al bone he aling

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o rm s o f s p lin t s , ca s t s , a n d o r t o s e s Splints Casts Split casts Orthose s and re m ovable casts

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Pre t re a t m e n t m e d ica l in fo rm a t io n a n d in fo rm e d co n s e n t e d u ct io n o f

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o n e fra ct u re s

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u n ct io n a l t re a t m e n t e ne fits of functional tre atm e nt Indications for functional tre atm e nt

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St a ili a t io n o f fra ct u re s

Bio m e c a n ics o f ca s t s

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Po s t t re a t m e n t p a t ie n t in fo rm a t io n a n d ca s t c e c Cast care inform ation outine cast che c

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Ca s t e d gin g Ste ps for cast we dging Anal sis of m alalignm e nt algus angulation arus angulation Ante curvation angulation e trocurvation angulation

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Ca s t t re a t m e n t fo r ru is e s , s p ra in s a n d s t ra in s , in fe ct io n s , a n d n e r ve im p a irm e n t s

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No n o p e ra t ive fra ct u re ca re Advantage s of nonope rative fracture care Disadvantage s of nonope rative fracture care

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e fe re n ce s

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u r t e r re a d in g

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Principle s of casting

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, ran Se ibe rt, os Engele n

Prin cip le s o f

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Klaus Dre sing, ran Se ibe rt, os Enge le n

Alth ou gh th e old prin ciples o castin g h ave proven to be (an d still are) e ective, problem s can still occu r, su ch as th e sti en in g o join ts or th e occasion al trem en dou s loss o m u scle. In itially, ph ysician s began to ollow Lu cas-Ch am pion n ière, w h o w as n ot on ly th e rst to h igh ligh t th ese problem s bu t also th e rst to start teach in g th at w ith on ly a little im m obilization , an d a lot o u n ction al th erapy an d m assage, th e ractu re w ou ld h eal qu ite w ell [1]. Later, an even m ore e ective process w as developed by Loren z Böh ler, w h ose tech n iqu e w as based on th e prin ciple o im m obilizin g th e bon e ragm en ts an d adjacen t join ts in a u n ction al position , an d or on ly as lon g as n ecessary, or a good clin ical ou tcom e. His m eth od o ractu re treatm en t w as th ou gh t to ach ieve th e best resu lts, an d h e w as also th e au th or o several im portan t books an d n u m erou s pu blication s on n on operative ractu re treatm en t [2, 3]. Th is ch apter th ere ore explores th e u n dam en tal prin ciples o castin g as developed over tim e by th e leaders in th e eld, an d provides an overview o oth er im portan t prin ciples in clu din g th e basics o bon e h ealin g, u n ction al treatm en t, cast w edgin g, an d patien t in orm ation .

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In direct (or prim ary) bon e h ealin g, th e ractu re gap is very sm all (ie, less th an 0.5 m m ). Osteon s, th e ch an n els an d blood vessels o w h ich cortical bon e is com prised, cross rom on e side o th e ractu re to th e oth er. Th e cortical bon e rom both ractu re sides recon n ects by th e en d o th e process. Direct bon e h ealin g occu rs u n der con dition s o absolu te ractu re stability by direct osteon al rem odelin g w ith ou t callu s orm ation . Th e osteon s (kn ow n as Haversian system s) ru n lon gitu din ally alon g th e cortex, an d are bou n d to each oth er by cem en t lin es. Osteon s are orm ed arou n d a cen tral vessel, w ith su rrou n din g layers called lam ellae, w h ich are orien tated in to a h elical ash ion , each tw istin g in th e opposite direction to its n eigh bor. On th e bon e’s su r ace is th e periosteu m , w ith an ou ter brou s layer, an d an in n er cam biu m layer, w h ich con tain s progen itor cells th at replace old an d in ju red cells ( ig 3 ). Du rin g th e process o h ealin g, th e bon e is rem odeled. Th ere is a con stan t state o tu rn over as old bon e is rem oved an d n ew bon e is con tin u ally laid dow n . Cells called osteoclasts rem ove bon e, w h ile osteoblasts lay dow n n ew bon e. Th e balan ce betw een bon e rem oval an d bon e deposit is determ in ed by th e biom ech an ical loads on th e skeleton an d th e m etabolic n eed to m obilize, or store, calciu m ion s (Ca++) ( ig 3 ).

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In bon e h ealin g, th ere is a di eren ce betw een “direct” an d “in direct” h ealin g. Wh ile in direct bon e h ealin g is th e u su al w ay o h ealin g du rin g n on operative ractu re care in a cast or splin t, direct bon e h ealin g n orm ally n eeds absolu te stability (eg, rigid xation w ith lag screw s or com pression plate, so as to preven t in ter ragm en tary m otion ).

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A ractu re n ot on ly cau ses th e loss o stability o th e bon e, th e extrem ity itsel also loses its ph ysiological stability w h ile th e su rrou n din g so t tissu es are m ore or less com prom ised. As a n on operative (ie, n on in vasive) tech n iqu e o ractu re treatm en t, castin g h elps to keep th e ractu re in th e redu ced position by stabilizin g th e ractu re ragm en ts rom ou tside an d by “im m obilizin g” th e ractu re du rin g th e h ealin g process o th e bon e. How ever, castin g w ith redu ction an d im m obilization o a ractu re is a ch allen gin g task or every trau m a su rgeon . In recen t decades, a lot o n on operative ractu re care kn ow ledge h as been lost du e to an in creased pre eren ce or operative ractu re care, yet th e old prin ciples, w h ich are still applicable an d approved, sh ou ld be rem em bered an d accepted.

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ig 3 Sche m atic cut through of cortical bone Each he lical orie n tate d oste on ave rsian s ste m twists in the opposite dire ction to its ne ighbor m iddle The bone s surface is cove re d b the pe rios te um , including its inne r cam bium la e r, which contains a varie t of proge nitor ce lls right

e lical lam e llae Oste oproge nitors Pre oste oblasts Oste oblasts Oste oc te s Pe rioste um Cam bium la e r

steoclasts

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steoblasts

ig 3 In norm al bone the re is continual turnove r old bone is re m ove d b oste oclasts Ca re le ase and ne w bone is laid down b oste oblasts Ca inta e

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, ran Se ibe rt, os Engele n

Th e rem odelin g ph ase starts w ith cu ttin g con es crossin g th e cortical ractu re zon e rom each direction . Th e advan cin g osteon s, w ith osteoclastic cu ttin g con es at th eir tips, becom e tran s orm ation al u n its th at rem ove w oven (im m atu re) bon e (w h ich h as an irregu lar stru ctu re an d orien tation ), ollow ed by osteoblasts layin g dow n cylin ders o n ew lam ellar bon e (w ith h igh ly organ ized an d orien ted stru ctu re) ( ig 3 3 ). In d ire ct

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e a ct ive p a s e racture and inflam m ation

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Follow in g th e im pact or cau se o th e ractu re, so t-tissu e dam age, disru ption o blood vessels, an d separation o bon y ragm en ts can occu r. A h em atom a orm s an d th e periosteu m partly ru ptu res ( ig 3 4 ). Som e bon y ragm en ts are w ith ou t so t-tissu e attach m en t, an d w ith th at, becom e devascu larized an d n ecrotic ( ig 3 5 ).

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In direct (or secon dary) bon e h ealin g, w h ich occu rs du rin g n on operative ractu re treatm en t, in volves callu s orm ation arou n d th e ractu re area. It is divided in to th ree ph ases: • Reactive ph ase • Reparative ph ase • Rem odelin g ph ase.

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e m atoma form ation and partial rupture of the pe rioste um

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ig 3 3 Cutting cone s cre ate c lindrical bone form ations At the tip, oste oclasts re m ove old bone , followe d b oste oblasts, which la down ne w lam e llar bone

Ce ntral ve sse l Oste oc te s Oste oblasts Oste oclasts ove n bone

ig 3 5 ragm e nts can be com e ne crotic be cause of inte rruption of blood circulation

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Follow in g th is, th e vessels dilate, cau sin g a rise in local tissu e tem peratu re. In f am m ation th en occu rs, becau se in th e ractu re h em atom a a ran ge o cells start to accu m u late in clu din g m acroph ages, n eu troph il gran u locytes, m esen ch ym e stem cells, an d cytokin es, all o w h ich h elp to rem ove an d replace old an d in ju red cells. From th e periosteal cam biu m layer, progen itor cells are delivered to th e ractu re site ( ig 3 6 ). Osteoin du ctive grow th actors stim u late th e proli eration an d di eren tiation o m esen ch ym al stem cells. Osteoclasts rem ove n ecrotic bon e parts, an d th e h em atom a starts to becom e stabilized by brin bers orm in g a h em atom a callu s ( ig 3 ).

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In th is part o th e reactive ph ase, ch em ical an d m ech an ical actors stim u late callu s orm ation an d m in eralization . New vessels in vade th e h em atom a, an d th e h em atom a is colon ized by cells called broblasts, w h ich derive rom th e periosteu m . Gran u lation tissu e develops in th e ractu re gap, con sistin g o collagen bers, wh ich are produ ced by th e broblasts. Th ese collagen bers loosely lin k th e bon e ragm en ts ( ig 3 ).

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De live r of proge nitor ce lls from the pe rioste al cam bium

ig 3 The ingrowth of brin be rs into the fracture he matom a starts to stabili e it he m atoma callus

Collagen fibers

ig 3 During granulation, ne w ve sse ls and broblasts invade the he matom a The broblasts produce collage n be rs, which loose l lin the fragm e nts toge the r

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Authors

Klaus Dre sing, ran Se ibe rt, os Engele n

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e p a ra t ive p a s e Cartilage callus form ation

In th e reparative ph ase, th e gran u lation tissu e gradu ally di eren tiates in to brou s tissu e an d cartilage to orm so t callu s ( ig 3 ). So t callu s is an u n organ ized n etw ork o w oven bon e. am e llar bone de position

ig 3 ranulation tissue graduall diffe re ntiate s into brous tissue and brocartilage

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In th e n ext step, th e cartilagin ou s tissu e becom es calci ed, tran s orm in g in to h ard callu s. A ter so t-callu s lin in g o th e ractu re ceases, th e h ard callu s stage starts an d lasts u n til th e ragm en ts are rm ly u n ited by n ew bon e (3–4 m on th s postin ju ry). En doch on dral ossi cation orm s spin dle-sh aped bon e cu s, startin g at th e periph ery an d m ovin g tow ards th e cen ter, u rth er sti en in g th e h ealin g tissu e. Th e callu s cu is alw ays th icker th an th e n orm al diam eter o th e bon e, resu ltin g in a lon ger lever arm , w h ich is biom ech an ically m ore appropriate ( ig 3 ). Fin ally, th e callu s is con verted in to w oven bon e ( ig 3 ).

ig 3 Callus cuff form ation alwa s starts at the pe riphe r m ov ing towards the fracture gap

Woven bone

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The cartilaginous callus is transform e d into wove n bone

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In th e n al ph ase o in direct bon e h ealin g, bon e rem odelin g occu rs, eith er u n der traction (distractive strain ) or com pression (com pressive strain ). Cu ttin g con es tran s orm th e w oven bon e in to lam ellar bon e. Th e ractu re h ealin g process is com pleted w ith th e rem odelin g o th e m edu llary can al an d rem oval o part o th e extern al callu s. 3

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Fractu re h ealin g greatly depen ds on th e biological statu s o th e bon e ragm en ts an d on th e local so t tissu e, especially th e periosteu m . Bu t ractu re h ealin g is also in f u en ced by th e am ou n t an d kin d o m ovem en t.

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Du rin g th e so t-callu s ph ase, too m u ch m ovem en t or excessive strain risks tearin g th e repairin g tissu e an d can com prom ise callu s orm ation , a poten tial cau se o “delayed u n ion ” or “n on u n ion ” ( ig 3 , ig 3 3 ). Yet, m ovem en t is n ecessary or bon e h ealin g becau se it in creases m u scle activity, stim u lates vascu larity (ven ou s an d arterial f ow ), stim u lates callu s m atu ration , an d preven ts th rom boem bolic com plication s (see topic 9 Fu n ction al treatm en t in th is ch apter an d ch apter 4 Th rom bosis proph ylaxis). Bu t th e m obilization an d ph ysioth erapy m u st be adapted to t its stage o ractu re h ealin g (see Ta le 3 ). Th e problem in m obilizin g a patien t w ith a ractu red extrem ity is to n d th e correct balan ce betw een too m u ch an d too little.

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A ter a bon e ractu re, n orm al bon e h ealin g w ill occu r w ith in 6–8 w eeks, depen din g on th e location an d th e type o ractu re. In a period o 3–4 m on th s, ractu res n orm ally h eal over so t callu s, an d th ere is orm ation o h ard callu s. How ever, too m u ch m ovem en t in th e early ph ases o bon e h ealin g can resu lt in delayed u n ion or even n on u n ion . Oth er actors th at can a ect h ealin g in clu de so t-tissu e in ju ry w ith devascu larization , th e n on com plian ce o th e patien t, vascu lar diseases w ith in su cien t per u sion o bon e an d so t tissu e, an d sm okin g. Wh en a ractu re h as n ot h ealed w ith in th e u su al tim e ram e (variou sly estim ated bu t typically by 4 m on th s), th ere is said to be a delayed u n ion . I a ractu re ceases radiograph ic progress tow ard u n ion over a 3 m on th in terval, an d rem ain s u n u n ited a ter 6 m on th s, th ere is n on u n ion ( ig 3 3 ).

ig 3 Too m uch strain during the he aling proce ss can rupture the granulation tissue the collage n be rs bre a , and the proce ss of bone he aling is alte re d so m uch that de la e d or nonunion re sults

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Authors

Klaus Dre sing, ran Se ibe rt, os Engele n

Description

Symptomatology

Physiotherapy

Day 1

Hematoma callus: fracture hematoma with subse uent coagulation Fibrin fibers stabili e the hematoma

Unstable obile fragments

Lymphatic and venous decongestant measures

Within the hematoma a gelatinous structure forms Capillaries pervade the hematoma and the hematoma is converted to immature granulation tissue (connective tissue) a gelatinous callus

uscle pull and muscle tone narrow the fracture gap Fragments are unstable

Lymphatic and venous decongestant measures

Day 1 1

steoclasts break down dead and necrotic bone Fibroblasts chondroblasts and osteoblasts proliferate steoid matrix and chondroid matrix are formed (granulation callus)

Fracture is mobile

Isometric strengthening of the muscles Passive movement

Day 1

steoclasts break down dead and necrotic bone (the resorption fracture gap becomes wider) Formation of new bone Acallus cuff is formed (stabili ation) Callus and osteoid transformation to bony trabeculae (endochondral ossification)

Decrease in movement between the fragments lastic fixation

Transformation from passive to active mobili ation

Volume of callus decreases (modeling) estructuring of callus econstitution of medullary canal and medullary fat

Fracture is stable for exercises ony consolidation in the x-ray

Progressive weight bearing

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Pe riods of fracture he aling in humans in re lation to s m ptom atolog and ph siothe rap

Soft callus

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Delayed union 2 6 months 3

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ig 3 3 An e xam ple of nonunion, as shown unde r uore sce nt staining, showing conne ctive tissue but no bone de te ction within the nonunion gap ig 3 3 a De la e d union and nonunion De la e d union occurs if the fracture has not he ale d afte r approximate l m onths If the frac ture has still not he ale d afte r m onths or m ore , the re is nonunion

Proximal fragm e nt luore sce nt staining Nonunion gap No bone de te ction, but conne ctive tissue Distal fragm e nt

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No n o p e ra t ive fra ct u re ca re

Redu ction : Fractu re ragm en ts m u st be redu ced in order to restore con tact w ith each oth er, ie, th e distal ragm en t w ith th e cen tral ragm en t(s) an d th e proxim al ragm en t, an d recreate u n ction ally acceptable lim b align m en t (ie, axis, rotation , an d len gth ).

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Each body region h as its ow n criteria, bu t in gen eral, th ere are a n u m ber o precon dition s or th e u se o a plaster or syn th etic cast in ractu re treatm en t. On e o th e m ost im portan t o th ese is th at th e so t-tissu e en velope allow s or th e application o a cast; as opposed to th e case o an in ected w ou n d n eedin g daily ch an ge o dressin g, or i th e ractu re w as u n stable an d so an extern al xator w ou ld be m ore su itable. Addition ally, patien ts th at n eed con tin u ed in tu bation an d an esth esia over a lon ger period o tim e w ou ld particu larly ben e t rom su rgical ractu re stabilization , as skin con dition s can n ot be ch ecked daily ben eath a plaster cast, an d i u n con sciou s, th e patien t can n ot com m u n icate th e eelin g o pain ben eath th e cast, eg, rom pressu re sores. Neverth eless, th ere are a n u m ber o advan tages th at n on operative ractu re care h as over operative treatm en t. Moreover, as society lives lon ger, th e n u m ber o patien ts n ot su itable or su rgery du e to th eir m edical an d m en tal statu s con tin u es to rise. An d or th ose in poorer cou n tries, an econ om ic poin t o view also h as to be taken in to con sideration w h en ch oosin g treatm en t option s. Th ere ore, an y n on operative treatm en t m u st be con du cted as e ectively as possible, keepin g in m in d th at later on , th e patien t’s statu s m igh t n ot allow ollow -u p su rgery. Providin g th at good resu lts are ach ieved by redu cin g th e ragm en ts, th e qu estion o h ow to proceed, eith er n on operatively or su rgically, m u st be determ in ed early on , togeth er w ith th e patien t. Both patien t an d su rgeon h ave to be aw are o all th e option s or th eir u rth er plan n in g. Th e prin ciples o castin g are govern ed by th ree im portan t key poin ts, th e th ree Rs: • Redu ction • Reten tion • Reh abilitation .

Reten tion : Fractu re ragm en ts m u st be kept in th e redu ced position an d im m obilized u n til bon e h ealin g o th e ractu re is ach ieved. Reh abilitation : Restoration o u n ction w ith an early start to u n ction al th erapy; rst, th e ree join ts du rin g cast im m obilization , ollow ed by u n ction al th erapy o th e en tire extrem ity a ter cast rem oval. Th e prim ary goal o cast treatm en t a ter trau m a is to ach ieve a pain less an d w ell- u n ction in g extrem ity as early as possible, u sin g th e th ree Rs. Every step o treatm en t h as to ocu s on th is n al goal an d, in som e cases, m igh t n eed adaptation o th erapeu tic option s or even ch an ges in th e treatm en t algorith m . 3

d va n t a ge s o f n o n o p e ra t ive fra ct u re ca re

Th e great advan tages o n on operative ractu re treatm en t over operative treatm en t are: • No n eed or su rgical resou rces an d logistics • Norm ally, n o dan ger o su rgically-in du ced or im plan trelated in ection or com plication s • Redu ced risk rom gen eral an esth esia • No n eed or su bsequ en t im plan t rem oval by su rgery. Addition ally, th ere are circu m stan ces th at m ake som e ractu res m ore su itable or con servative th erapy by plaster or syn th etic casts th an oth ers. Yet, even kn ow in g th at every ractu re can be treated n on operatively, it is a qu estion o acceptan ce o th e expected resu lt, especially in regard to th e expectation s o su rgeon an d patien t con cern in g th e radiological an d, even m ore im portan tly, th e clin ical ou tcom e.

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, ran Se ibe rt, os Engele n

Moreover, it is im portan t th at patien ts w h ose ractu res are treated w ith ou t su rgical redu ction an d xation receive periodic reassessm en t by x-ray ch eck o redu ction , an d clin ical exam in ation w ith con tin u ou s docu m en tation o capillary re ll (u n distu rbed blood f ow ), active an d passive n eu rological in tegrity (n o sen sation de cit or loss o m u scle activity), an d pain less in tact skin con dition s. Every im m obilization u sin g a cast sh ou ld be ollow ed by regu lar rech eck o m otor u n ction , vascu larization , an d sen sitivity, startin g directly a ter th e cast is applied.

We m u st rem em ber th at th e ath er o con servative ractu re treatm en t, Loren z Böh ler, stated in 1929 in h is book The Treatment of Fractures th at con servative (n on operative) ractu re treatm en t n eeds care u l atten tion , exact tech n iqu e, an d able ph ysician s [2].

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Som e disadvan tages o n on operative ractu re m an agem en t w ith plaster or syn th etic casts m u st also be addressed: • Casts requ ire in ten sive su rveillan ce (at least on ce a w eek u n der n orm al circu m stan ces), an d a cooperative patien t • Fu ll u n ction al recovery can at tim es be delayed; also depen din g on th e age o th e patien t • Th ere is th e possibility o developin g “ ractu re disease” w ith con tractu re, loss o m u scle an d/ or bon e (dem in eralization ), accom pan ied by pain an d sw ellin g, w h ich can lead to a disastrou s loss o u n ction , th e so-called com plex region al pain syn drom e (ref ex sym path etic dystroph y, w ith associated dem in eralization called Su deck’s atroph y).

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is a d va n t a ge s o f n o n o p e ra t ive fra ct u re ca re

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Ph ysician s m u st rem em ber th e im portan ce o overall an atom ical align m en t, as w ell as th e act th at lim b sh orten in g is m ore acceptable or con solidation th an a gap w ith n o ractu re ragm en t con tact.

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Th e decision m u st be based on : • Th e orm o th e ractu re (sh a t, m etaph yseal, in traarticu lar w ith ou t step-o or im paction ) • Th e absen ce o displacem en t, especially a ter redu ction • Th e degree o m alalign m en t – Lim ited axial (varu s, valgu s, an tecu rvation , or retrocu rvation < 5°) – Rotation al (in tern al, extern al rotation < 10°) • Len gth discrepan cy.

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o rm s o f s p lin t s , ca s t s , a n d o r t o s e s Klaus Dre sing, os Enge le n

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Today, casts an d splin ts are n ot on ly u sed or ractu re treatm en t bu t also as a prelim in ary m easu re to prepare or con dition so t tissu es, an d very o ten or patien ts n ot im m ediately t en ou gh or su rgery. In addition , casts are o ten in dicated as postoperative protection devices. A ter su rgical in terven tion , th e postoperative in f am m ation can be dim in ish ed by sh ort-term cast im m obilization . Addition ally, protection by extern al im m obilization is som etim es n eeded w ith n on com plian t patien ts, or w h en ever th e stabilized osteosyn th esis is n ot adequ ate to allow w eigh t bearin g or exercise. Severe bru ises, an d join t sprain s an d strain s m ay requ ire sh ort-term cast im m obilization in order to redu ce pain an d sw ellin g. Ru ptu res o ten don s an d m u scles can also be treated w ith im m obilization , w ith u n ction al bracin g or castin g (see ch apter 11.1 Ligam en t an d ten don in ju ries). Cast im m obilization or treatm en t by orth osis m ay be in dicated to im prove lim b u n ction in patien ts w ith n erve im pairm en ts, palsy or paresis, eg, palsy o th e radial n erve or com m on peron eal n erve (see ch apter 11.2 Nerve in ju ries). Adju van t im m obilization in cases o in ected lim bs, arth ritis, an d aseptic sw ellin g can su pport n on operative treatm en t an d redu ce treatm en t tim e (see ch apter 12 In dication s or n on operative treatm en t o in ection s). Special dyn am ic casts ( or exam ple, a Qu en gel-h in ge (exten sion -desu blu xation ) orth osis or th e kn ee, or or th e n ger join ts to regain f exion an d exten sion in th e PIP join t) cou ld be in dicated w h en restriction o m ovem en t or join t sti n ess is observed a ter treatm en t.

Casts can be distin gu ish ed accordin g to th e variou s m aterials in volved in th e im m obilization : • • • •

Plaster o Paris Syn th etic m aterials Ban dages Tapes

an d by th e speci c tech n iqu es an d application s u sed: • • • •

Splin ts Casts Split casts Orth oses.

Casts are cu stom m ade or a patien t u sin g ban dage-like m aterials th at h arden du rin g application . Ch apter 6 Properties o cast m aterials ou tlin es th e speci c eatu res o th ese m aterials. Th ey can also be u sed to m ake splin ts. A great variety o pre abricateed an d cu stom -m ade orth oses are also available or im m obilization an d or u n ction al ractu re treatm en t. Th is book presen ts ractu re braces an d oth er orth oses m ade rom castin g m aterials. Both plaster o Paris (POP) an d syn th etic m aterials can be applied or prim ary, tem porary, secon dary, or de n itive treatm en t o acu te ractu res, sprain s, or strain s. For im m obilizin g in ected so t tissu es an d ten don s, extrem ities, or join ts, sim ple lon gitu din al splin ts can be u sed. Splin ts u sin g a U-sh aped slab tech n iqu e (w h ere th e m aterial is applied dow n on e side o th e lim b an d back u p th e oth er) or su garton g splin ts (Böh ler U-POP casts) are u sed to im m obilize th e u pper extrem ity, orearm , or in ju ries o th e an kle join t. sh ow s exam ples o a splin t ( a ), a cast ( ), a split cast ( c), an d an orth osis (a cu stom - abricated ractu re brace) ( d ). ig 3

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, ran Se ibe rt, os Engele n

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The m a or form s of splints and casts

An e xam ple of a splint An e xam ple of a full circum fe re ntial cast

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An e xam ple of a split cast, which has be e n split and re wrappe d with gau e bandage to allow for swe lling

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An e xam ple of an orthosis showing a fracture brace whe re ve lcro straps pe rm it e as re m oval and re ad ustm e nt of tightne ss

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Principle s of casting

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Sp lin t s

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I com plete im m obilization is n ot requ ired, eg, in order ju st to decrease sw ellin g or to protect again st u rth er so t-tissu e dam age, a n on circu m eren tial “splin t” m ade ou t o POP or syn th etic m aterial can be applied. Du rin g prim ary treatm en t o ractu res an d join t in ju ries in th e em ergen cy departm en t, th ese types o n on circu lar casts are n orm ally applied sin ce acu te an d secon dary sw ellin g can occu r in th e cou rse o treatm en t. An oth er in dication or th e application o a splin t is postoperative treatm en t or as protection a ter osteosyn th esis in order to en su re th at th e cast does n ot con f ict w ith postoperative sw ellin g. Be ore applyin g a splin t, a tu be ban dage or stockin ette is pu lled over th e extrem ity, an d th e appropriate am ou n t o paddin g is applied. It is im portan t to u n derstan d th at excessive paddin g w ill com prom ise th e im m obilization e ect o th e splin t as th ere w ill be too m u ch space betw een th e variou s layers o th e cast an d th e skin . Loren z Böh ler preerred a n early u n padded bu t w ell m olded plaster. He on ly u sed paddin g to protect bon y prom in en ces. Wh en u sin g plaster o Paris or syn th etic m aterial, th e location o th e in ju ry an d th e stren gth o th e patien t determ in e h ow m an y layers o u n dercast paddin g sh ou ld be u sed. To in crease stability, th e splin t sh ou ld cover abou t tw o th irds o th e circu m eren ce o th e extrem ity. An oth er possibility is th e u se o sm all strips o splin t m aterial to rein orce its stren gth in areas w h ere m ore stability is n eeded, eg, arou n d join ts. Wh en u sin g POP, a splin t or th e u pper extrem ity typically con sists o 8–10 layers, an d or th e low er extrem ity 12–16 layers are n eeded. As th e rigidity o syn th etic m aterial is greater, th e n u m ber o layers n eeded or th e u pper extrem ity is on ly 6–8, an d or th e low er extrem ity 9–12 layers is su cien t.

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Ca s t s

A circu m eren tial “cast” is u sed w h en ever a h igh er degree o im m obilization is n eeded, or in secon dary treatm en t. Th e stability o a u lly circu lar cast is m u ch h igh er th an in a splin t an d it allow s th e patien t to be m ore active. A cast allow s w eigh t bearin g an d w alkin g, w h ich is n ot possible w ith a splin t or split cast. To m ake th e cast stable en ou gh or w eigh t bearin g it m igh t be n ecessary to com bin e th e circu lar w in din gs w ith addition al strips or lon gu ettes o splin t m aterial in order to rein orce th ose areas o th e cast w h ere it m igh t break easily, especially in th e vicin ity o join ts. In a cast, th e extrem ity is covered w ith a tu be ban dage (stockin ette) an d th e requ ired am ou n t o paddin g is applied. Th e cast roll is th en w rapped arou n d th e lim b rom distal to proxim al. Wh ile w in din g, th e cast m aterial sh ou ld overlap at least 50% in order to avoid w eak spots (th rou gh ou t th is text th is is re erred to as th e “h al -overlappin g tech n iqu e”). In areas w h ere th e m axim u m load on th e extrem ity occu rs, m ore w in din gs are n ecessary. For a cast, 8–10 layers o POP or 4–6 layers o syn th etic are requ ired in order to ach ieve en ou gh stability or th e u pper extrem ity. For low er extrem ity casts, 12–14 layers o POP or 6–8 layers o syn th etic cast m aterial are recom m en ded. All circu m eren tial casts applied or prim ary treatm en t ( rst cast a ter in ju ry or su rgical procedu re) m u st be split com pletely an d secu red w ith an adh esive ban dage. Oth erw ise, postoperative so t-tissu e sw ellin g w ill be lim ited by th e cast resu ltin g in com pression o th e so t tissu es. Th is m igh t cau se a com partm en t syn drom e. Moreover, sin ce som e cast m aterials an d ban dages can sh rin k as th ey dry, th e ph ysician / cast tech n ician sh ou ld n ot on ly split an d loosen th e cast, bu t also divide all u n derlyin g layers o paddin g a ter th e cast m aterial h as set (h arden ed).

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Th e cast is split com pletely u sin g scissors or a cast saw an d w iden ed w ith a cast spreader. An oth er tech n iqu e is to rem ove a 1 cm strip in order to ach ieve m ore space. Th is gap is lled w ith paddin g an d th e split cast is th en w rapped w ith an elastic ban dage in order to preven t swellin g alon g th e gap.

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r t o s e s a n d re m o va le ca s t s

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An “orth osis” is a rem ovable extern al orth opedic device th at preven ts or con trols th e m ovem en t o th e lim bs, h ead, or spin e. Wh ile casts are th e dom ain o th e su rgeon an d cast tech n ician , orth oses are typically applied by oth er h ealth care pro ession als, su ch as orth otists an d occu pation al th erapists, an d th e devices th em selves are u su ally easy to rem ove an d reapply, even by th e patien t. Exam ples o orth oses in clu de th e h alo vest or cervical collars or th e h ead an d n eck area, or strap-on braces or th e arm or an kle. Th e m ain types o orth oses in clu de:

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Wh en a circu m eren tial cast is applied to a resh ractu re, or postoperatively, it sh ou ld be open ed or split lon gitu din ally to becom e a “split cast”, to allow posttrau m atic or postoperative sw ellin g to occu r w ith ou t in creasin g tissu e pressu re (see topic 11 Cast splittin g tech n iqu es an d cast rem oval in ch apter 14.1 Overview o cast, splin t, orth osis, an d ban dage tech n iqu es). With ou t splittin g th e cast, com plication s can occu r, su ch as im paired ven ou s or arterial circu lation , n erve irritation , or com partm en t syn drom e, w ith poten tially perm an en t in ju ry to so t tissu es, especially m u scles an d n erves.

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• Com m ercially available pre abricated devices, with variation in th eir ability to be con tou red to t th e patien t • Cu stom - abricated devices m ade o leath er, plastic, m etal, an d oth er com pon en ts, w ith or w ith ou t u sin g a m old o th e patien t' s lim b • Devices m ade rom sh eets o th erm oplastic m aterial speci cally m olded to th e con tou rs o th e patien t' s lim b • Rem ovable casts an d splin ts m ade w ith syn th etic castin g m aterials, developed speci cally or each patien t.

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Th ere is great variation in th e costs an d access to th e rst th ree categories o orth osis arou n d th e w orld, an d are beyon d th e scope o th is book, bu t still m ay be w orth y o con sideration or certain th erapeu tic n eeds. How ever, orth oses m ade rom castin g m aterials are m ade to speci cally m eet th e n eeds an d sh ape o th e patien t, an d th e m aterials h ave a low er cost. An d by in corporatin g oth er m aterials, th eir com bin ed adju stability an d rem ovability represen t a valu able advan ce in th e developm en t o cast tech n ology. Orth oses m ade rom castin g m aterials are o ten re erred to as " ractu re braces" an d are particu larly w ell su ited or u n ction al ractu re treatm en t ( u n ction al exercises, am bu lation w ith partial or u ll w eigh t bearin g, an d u se o th e im m obilized part or selected activities o daily livin g) (see ch apters 15.5 Sarm ien to h u m eral brace u sin g syn th etic, com bicast tech n iqu e; an d 16.9 Sarm ien to tibial brace u sin g syn th etic, com bicast tech n iqu e). It is best to apply an orth osis a ter posttrau m atic sw ellin g h as resolved. I a ractu re brace is design ed so th at tigh tn ess o t can be adju sted by th e patien t or optim al su pport, it becom es even m ore adaptable. Tem porary ractu re brace rem oval can also be h elp u l or som e ph ysical th erapy treatm en ts.

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Principle s of casting

Rem ovable splin ts an d casts can be secu red in variou s w ays. In addition to an over-w rappin g ban dage, straps w ith h ook an d loop asten ers (eg, velcro) perm it easy application an d rem oval, an d th e opportu n ity to in crease brace tigh tn ess or u n ction al activities. Som etim es, a cast can be split tw ice (bivalved), u su ally 180° apart, m akin g its rem oval an d reapplication easy. Bu t even w ith m u ltiple w raps, stability is com prom ised becau se circu m eren tial tigh ten in g is n ot possible. I th e split in a cast is m ade so it overlaps adju stably, both t an d m ech an ical su pport can be optim ized.

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Pre t re a t m e n t m e d ica l in fo rm a t io n a n d in fo rm e d Klaus Dre sing co n s e n t

A ter com plete exam in ation o th e patien t an d stu dy o th e type o ractu re sh ow n in th e x-ray, th e patien t is in orm ed abou t th e in ten ded treatm en t. Ph ysician s sh ou ld take in to con sideration th at an in orm ed patien t is a m ore cooperative patien t an d th u s th e ou tcom e w ill u su ally be better. Th e person al righ ts o th e patien t h ave to be respected at all tim es. Th e su rgeon n eeds to distin gu ish tw o situ ation s: • Em ergen cy procedu res • Elective procedu res. In em ergen cy cases, th e in orm ed con sen t is o ten on ly given orally. Th e su rgeon h as to con rm an d docu m en t th at th e treatm en t an d th e special procedu re (redu ction , cast) are requ ired im m ediately. In n on em ergen cy ractu re treatm en t, th e patien t h as to be in orm ed abou t th e risks an d altern ative treatm en t option s prior to treatm en t. Th is requ ires a w ritten in orm ed con sen t. I th e patien t is n ot able to sign , eg, becau se o ractu re or in ju ry o th e dom in an t h an d, th e oral in orm ed con sen t is docu m en ted by th e su rgeon an d, i possible, sign ed by a w itn ess. In case o m in or patien ts, w ritten paren tal con sen t is alw ays requ ired. In som e cou n tries (su ch as Germ an y), m edical treatm en t w ith ou t valid con sen t is legally regarded as an in ju ry accordin g to civil or crim in al law , even i th e ou tcom e is su ccess u l [4]. Exem ption rom pu n ish m en t requ ires au th orization by th e con sen t o th e patien t. Su ch “in orm ed con sen t” in clu des docu m en tation th at th e ph ysician h as in orm ed th e patien t abou t th eir m edical con diton an d th e relevan t aspects o treatm en t [4]. In special clin ical situ ation s, it is di cu lt to obtain in orm ed con sen t rom th e patien t, eith er becau se th e patien t is u n able to provide con sen t or becau se o a li e-th reaten in g situ ation th at requ ires im m ediate in terven tion [5]. Th e in orm ed con sen t docu m en t m u st speci y th e risks an d con sequ en ces o th e in terven tion [5]. Con sen t sh ou ld be obtain ed prior to castin g procedu res w h en ever th e patien t is able to ollow th e explan ation s. Th e patien t sh ou ld be in orm ed abou t altern ative treatm en t procedu res, an d abou t th e cou rse an d risks o treatm en t [6]. Th e in orm ed con sen t sh ou ld be u n derstan dable or patien ts o all ages. In case o m in ors, th e legal gu ardian (s) h ave to be in orm ed an d th ey h ave to sign th e orm .

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, ran Se ibe rt, os Engele n

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Su rgeon s applyin g casts h ave to be in orm ed an d train ed in th e correct application o casts, oth erw ise th eir treatm en t m igh t (in som e cou n tries) be classi ed as w ill u l n egligen ce. Th e pro ession al, m edical, an d eth ical diligen ce is violated i , u n der sim ilar con dition s, a pru den t an d train ed h ealth care provider w ou ld carry ou t treatm en t in a di eren t m an n er or i th e treatm en t pu blish ed in literatu re di ers com pletely.

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Th e list o possible local risks a ter cast application com prises: • Skin an d so t-tissu e alteration • Bru isin g ben eath th e cast • Pressu re n ecrosis • Allergic reaction to cast m aterial • Skin lesion s, abrasion s by cast saw s • Bu rn in ju ries • Sw ellin g • Distu rbed arterial or ven ou s blood circu lation • Nerve irritation • Pressu re in ju ry o a n erve (eg, peron eal, u ln ar, an d su per cial (sen sory) radial n erve) • Mu scle redu ction / atroph y • Com partm en t syn drom e • Redisplacem en t o th e ractu re • Secon dary redislocation o join ts • Displacem en t o th e cast • Breakin g o th e cast, especially w h en u sin g POP • Join t sti n ess • Mu scu lar con tractu res • Sh ou lder overload or overu se in ju ries rom u sin g cru tch es • Pain in adjacen t join ts cau sed by abn orm al postu re.

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Alw ays rem em ber th at at th e begin n in g o an y n on operative ractu re treatm en t, patien ts an d th eir relatives, paren ts, or th ose accom pan yin g th em , sh ou ld rst be in orm ed abou t th e risks o a cast, an d advice sh ou ld be given by th e su rgeon on h ow to respon d in case o problem s. Wh en problem s do arise w ith th e cast, th e patien t is obliged to im m ediately retu rn to th e clin ic.

Th e list o possible gen eral risks a ter cast application com prises: • Th rom bosis an d em bolism o th e im m obilized lim b • Mu scu lar atroph y • Osteopen ia • Region al pain syn drom e (RPS) • Back pain a ter u n ilateral redu ction o w eigh t • Back pain by relative lim b len gth en in g o th e casted low er extrem ity • Sh ou lder-n eck pain syn drom e w ith an u pper extrem ity cast.

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Principle s of casting

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As th e rst option in treatin g a ractu re sh ou ld alw ays be n on operative treatm en t, th e ractu re sh ou ld be “redu ced” as early an d as accu rately as possible. I th e in itial con servative trial h as ailed, operative ractu re treatm en t th en becom es th e on ly option . All patien ts h ave th e righ t to get th e u ll atten tion an d receive th e best e orts o th eir su rgeon in order to ach ieve a good resu lt, even w h en receivin g n on operative treatm en t. Prom pt redu ction o th e ractu red bon e is very im portan t w h en ever th e skin is en dan gered du e to in n er pressu re cau sed by displaced bon e ragm en ts. In special region s, eg, th e distal tibia, th e an kle join t, an d above th e kn ee—especially in th e case o displacem en ts w ith ten sion on th e skin — im m ediate redu ction in order to preven t su bsequ en t skin problem s or even n ecrosis is o u tm ost im portan ce. Th e sam e is tru e i de orm ity im pairs arterial blood f ow , as m ay h appen w ith a ch ild’s su pracon dylar h u m eral ractu re, or a kn ee dislocation . A su rgical in cision th rou gh badly in ju red skin an d su bcu tan eou s tissu e m ay break dow n a ter an early operation . Delayin g th e operation u n til th e so t-tissu e en velope h as recovered h elps to avoid su ch problem s. Open ractu re w ou n ds are less seriou s i cau sed by in direct trau m a, typically a torsion al in ju ry resu ltin g in a spiral ractu re w ith sh arp poin ted en ds. Th ese can per orate th e skin rom in side ou t. Un less seriou sly con tam in ated (eg, rom arm yard or in du strial dirt), th e risk o in ection o su ch in ju ries is little m ore th an th at o closed in ju ries, assu m in g adequ ate w ou n d toilette h as been ach ieved w ith ou t u n du e delay. Open ractu re w ou n ds du e to a orce applied directly to th e bon e at th e ractu re site produ ce m ore dam age to th e su rrou n din g skin an d so t tissu es ( ractu re zon e), o ten w ith greater con tam in ation rom ou tside (eg, car again st leg). In creased so t-tissu e in ju ry is associated w ith h igh er rates o in ection an d im paired ractu re h ealin g. Fractu res du e to direct trau m a are u su ally tran sverse, sh ort obliqu e, an d/ or com m in u ted. Adequ ate debridem en t, com bin ed w ith th e prom pt release o an y so t-tissu e ten sion rom sw ellin g or de orm ity, are su rgical m easu res in ten ded to redu ce th e risks o in ection an d delayed ractu re h ealin g. A bon e en d trapped ou tside th e skin , typically th rou gh a tigh t open w ou n d, can be re-placed in side th e so t-tissu e en velope w ith an in stru m en t, sterile gloved n ger, or by en largin g th e

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w ou n d w ith a scalpel. Th is m easu re also serves to protect th e partially trau m atized skin rom addition al pressu re by th e bon e an d to preven t su bsequ en t skin n ecrosis. Healin g o bon e is on ly possible w ith h ealth y an d in tact so t tissu es su rrou n din g th e ractu re zon e. Oth erw ise, con solidation w ill at least be prolon ged, an d i w orse com es to w orst, in ection can set in , w h ich can even en dan ger th e patien t’s li e. Redu ction o a ractu re is ach ieved by traction an d reversin g th e ractu re m ech an ism in order to brin g th e distal ragm en t back in to place. To keep th e patien t ree o pain , local or gen eral an esth etics can be u sed. Traction can be don e eith er by h an d or by placin g w eigh t on an extrem ity in on e step or con tin u ou sly. Traction can on ly be rem oved a ter stabilization (h arden in g/ settin g o th e plaster) an d im m obilization o th e ractu red bon e(s) is ach ieved. In a so-called Colles’ ractu re, in w h ich th e distal ragm en t o th e radiu s is im pacted, dorsally displaced, dorsally an gu lated, an d su pin ated, th e distal ragm en t n eeds rst to be disim pacted by m an ipu lative m an u al traction , in creasin g displacem en t, an d th en m oved an teriorly over th e proxim al ragm en t ollow ed by palm ar f exion at th e ractu re. Th en , releasin g traction restores con tact o th e volar cortical su race at th e ractu re site, in creasin g stability, i dorsif exion o th e ractu re is preven ted. Fin ally, pron ation is added to correct th e typical su pin ation m alalign m en t, an d in crease stability. Sim ple traction alon e alm ost n ever corrects th e Colles' ractu re' s m u ltiple de orm ities. Becau se closed m an ipu lation an d cast or splin t application can be in su cien t to redu ce som e ractu res, it is h elp u l to h ave addition al aids. An assistan t, or w eigh ts w ith slin gs, can in prove cou n tertraction . Som etim es, on e or m ore percu tan eou sly in serted pin s or w ires can h elp ach ieve redu ction , or m ain tain traction , perh aps by bein g in corporated in to th e cast proxim ally or distally to th e ractu res. Sterile equ ipm en t an d tech n iqu e are o cou rse essen tial. Flu oroscopy, w ith appropriate protective sh ieldin g, can also be h elp u l. In som e in stan ces, it is possible to u se pre orm ed splin ts or ban dages, bu t m ore o ten th an n ot, stan dard cast m aterials, expertly applied, provide better t, better paddin g, an d th u s optim al im m obilization or a resh ractu re. Th ere are som e com m ercially available kn ee braces th at are u se u l to lim it m otion in special situ ation s, eg, h ealin g o

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, ran Se ibe rt, os Engele n

Th e m ain prin ciple is to rst keep th e patien t alive, an d th en to keep th e lim b alive as w ell. Accu rate redu ction o ractu res provides th e best possible ou n dation or good n on operative treatm en t. Th e goal, u ll recovery o u n ction , alw ays h as to be kept in m in d.

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Stabilization o ractu re ragm en ts or join ts h elps to redu ce pain by avoidin g m otion . Pain relie is on e o th e m ost im portan t prerequ isites o h ealin g. I patien ts eel pain , th ey w ill eel ill. I patien ts try to m ove, th e ractu re ragm en ts w ill m ove as w ell, an d th u s cau se pain an d, as th e an tidrom ic con tractu re o th e adjacen t m u scles tries to stabilize th e ragm en ts, even m ore pain w ill be cau sed an d th e m alalign m en t cou ld w orsen . Un der su ch con dition s, it w ill be im possible to en cou rage patien ts to m ove or even to get ou t o bed. Moreover, th ere m ay be an in creased loss o m u scle an d bon e. Du e to th e redu ced m u scle u n ction an d th e resu ltin g redu ced blood f ow , sw ellin g w ill n ot su bside. Th ereore, troph ic ch an ges w ill dim in ish th e ch an ce or good resu lts an d h ealin g w ill take m u ch lon ger or, u n der su ch circu m stan ces, m igh t n ot be ach ieved at all.

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Wh en ever im m obilization is n eeded bu t com prom ised so t tissu es are presen t, it is som etim es h elp u l to in corporate w in dow s w ith in th e plaster (m ore in orm ation on cast w in dow s is ou n d in ch apter 14.1 Overview o cast, splin t, oth osis, an d ban dage tech n iqu es). I th e patien t is allow ed to bear w eigh t an d th e cast h as a w in dow over th e lateral an kle, th is m u st be closed secu rely du rin g w alkin g to preven t severe local sw ellin g (“w in dow edem a”).

St a ili a t io n o f fra ct u re s

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th e m edial collateral ligam en t or a ter m en iscu s repair. Th ey allow con trolled join t m ovem en t th at accelerates h ealin g an d im proves orien tation o collagen brils w ith in th e h ealin g scar tissu e. Ten don h ealin g is kn ow n to be im proved by a low traction orce, bu t excessive ten sion can cau se ailu re o a ten don repair. Th u s, in som e cases, it is h elp u l to u se rem ovable im m obilizin g splin ts or casts, w h ich allow lim ited ph ysical th erapy, local w ou n d con trol, an d scar th erapy.

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Stabilization o ractu re ragm en ts can eith er be ach ieved by extern al im m obilization (casts or splin ts), or in tern ally by platin g an d bridgin g or by an in tram edu llary rod, typically w ith proxim al an d distal lockin g bolts to m ain tain len gth an d rotation al align m en t. In traarticu lar ractu res w ith gaps an d/ or depressed areas h ave to be redu ced an atom ically, som etim es au gm en ted by bon e su bstitu tes or can cellou s bon e gra ts, an d xed w ith absolu te stability, u su ally u sin g lag screw s an d bu tress plates. Early m otion o articu lar ractu res sh ou ld be en cou raged bu t sign i can t load bearin g sh ou ld aw ait radiograph ic sign s o h ealin g, an d progress gradu ally, gu ided by absen ce o pain . An oth er option or ractu re stabilization is th e extern al xator. Th is in volves an extern al ram e, con n ected w ith w ires or pin s to bon e proxim ally an d distally to a ractu re. Su ch a ram e can be attach ed to both en ds o a ractu red bon e, or m ay cross a join t, in th e case o an articu lar ractu re, to avoid loadin g th e articu lar su r ace o th e in ju red join t. Depen din g u pon th eir design an d application , extern al xators can perm it w eigh t bearin g an d/ or join t m otion , as ch osen or a particu lar in ju ry an d patien t. For all ractu res, it is im portan t to provide en ou gh stability to con trol pain , m ain tain ractu re align m en t, prom ote h ealin g o bon e an d so t tissu es, an d perm it m obilization o th e patien t. As soon as th e ractu re is stable en ou gh , con siderin g its pattern , location , m ean s o th erapeu tic stabilization , an d exten t o h ealin g, progressive u n ction al u se sh ou ld be en cou raged, w ith in th e patien t' s ran ge o com ort.

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Principle s of casting

Im m obilization o ractu res w ith a POP cast m ay also n eed stabilization o th e adjacen t join t in order to m in im ize m otion o th e ractu re ragm en ts an d redu ce pain an d sw ellin g. I stabilization o th e ragm en ts is n ot adequ ate, each m u scle con traction an d m otion at th e en ds o th e ractu re ragm en ts w ill cau se pain . Th ere ore, th e ragm en ts sh ou ld h ave good con tact as w ell as correct axial an d rotation al align m en t. As th ere is sw ellin g an d h em atom a in th e rst ph ase a ter th e ractu re, care m u st be taken th at th e cast is n ot too tigh t. Oth erw ise, pain w ill in crease an d pressu re dam age to th e su rrou n din g tissu es m igh t brin g abou t disastrou s resu lts perh aps even leadin g to am pu tation . Th ere ore, prim ary im m obilization can n ot be don e w ith a closed (circu lar) cast. Non circu m eren tial splin ts or split casts are th e m eth ods o ch oice. A ter sw ellin g is redu ced an d th e h em atom a h as been resorbed, a circu lar cast can be applied an d m ore activity allow ed. Early ran ge o m otion exercises or all m obile join ts are en cou raged in order to preven t sti n ess. Elevation o th e in ju red lim b h elps to con trol sw ellin g, as does u n ction al u se, w h ich also h elps to avoid atroph y an d join t sti n ess, as w ell as to prom ote ractu re h ealin g. Du ration o stabilization sh ou ld be as sh ort as n ecessary, an d th e cast sh ou ld exten d on ly as ar as n eeded. Norm ally, th e “th ree-poin t stabilization tech n iqu e” (see ig 3 6 in topic 10 o th is ch apter) w ill keep align m en t, axis, an d rotation w ith in acceptable lim its or th e du ration o im m obilization an d bon y h ealin g.

u n ct io n a l t re a t m e n t

Klaus Dre sing

“Fu n ction al ractu re treatm en t” is th e early an d progressive u se o th e in ju red lim b du rin g ractu re h ealin g, as opposed to en orced rest an d restrictive im m obilization . It typically in clu des u se o casts or ractu re braces th at allow as m u ch u n ction as possible, w h ile providin g en ou gh su pport to keep ractu re site m otion w ith in th e lim its requ ired or bon e h ealin g, as w ell as to preserve adequ ate ractu re align m en t. Exam ples in clu de: • Early m obilization an d exercises w ith in pain toleran ce or patien ts w ith stable vertebral or pelvic ractu res • Slin gs an d exercises or m an y proxim al h u m eru s ractu res • Fractu re braces, ran ge o m otion an d m u scle isom etrics or h u m eral sh a t ractu res • Abbreviated orearm casts or braces or isolated u ln ar ractu res • Weigh t bearin g patella ten don bearin g casts or braces or tibial sh a t ractu res. With n on operative ractu re treatm en t, th e ph ysician m u st distin gu ish betw een im m obilization an d n on im m obilizin g u n ction al treatm en t, as cast- ree u n ction al treatm en t is a th erapeu tic option or som e ractu re in dication s. Fu n ction al treatm en t a ter su rgery, especially in tram edu llary ractu re xation , is also an im portan t postoperative tool. Be n e fit s o f fu n ct io n a l t re a t m e n t

Th e com plete im m obilization o an extrem ity leads to castm ediated bon e m in eral loss [7], as rst described by Wol in Berlin in 1892 [8]. Th is is associated n ot on ly w ith decreased ph ysical activity du e to lim b ractu res [9], bu t also m easu rably altered activity o th e brain , as w ell as in du ced rapid reorgan ization o th e sen sorim otor system [10]. Fu r-

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Com parison of the stabilit of a tight tting cast using lle d a ,

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, ran Se ibe rt, os Engele n

Partial im m obilization , h ow ever, in h ibits certain m ovem en ts o join ts an d extrem ities bu t does n ot com pletely im m obilize th e join t. A secon d option is to keep extrem ities an d join ts rom bearin g loads bu t to preserve th e u n ction al activity o th e m u scu loskeletal apparatu s [12–16]. With partial im m obilization , u n ction al treatm en t is possible an d th u s th e u su al disadvan tages o im m obilization can be preven ted or at least redu ced. A ter th e rst period o w ou n d h ealin g, n o later th an a ter th e rst postoperative or postin ju ry w eek, u n ction al ollow u p treatm en t sh ou ld start. Th e am ou n t o m obilization depen ds on ractu re location , displacem en t, join t dislocation (i an y), so t-tissu e in volvem en t, n on operative versu s operative ractu re care, an d th e com plian ce o th e patien t. Th e positive ou tcom es rom u n ction al im m obilization resu lt rom : • Mech an ical e ects • Exteroceptive e ects • Sen som otor e ects • Psych ological e ects.

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Mech an ical e ects: Th e variou s cast an d im m obilization m aterials h ave di eren t ph ysical properties accordin g to elasticity, ben din g orce, an d adh esive orce. Th ese su pport ban dages an d cast m aterials bu ild a coh eren t system togeth er w ith th e u n derlyin g so t tissu es an d skin . Th ere ore, th ese tissu es are exposed to th e ben din g an d com pressive orces tran sm itted to an d/ or relayed by th e cast m aterial.

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Exteroceptive e ects: Th e coh eren t system (cast an d ban dage m aterial w ith u n derlyin g so t tissu e an d skin ) stim u lates m ech an oreceptors resu ltin g in an activation o m u scles, ten don s, an d join t capsu les.

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th erm ore, th ese ch an ges in th e cortex are also associated w ith skill tran s er rom th e in ju red to th e u n in ju red extrem ity [11]. Trau m a an d th e su bsequ en t im m obilization togeth er in du ce alteration s o th e so t an d h ard tissu es. Im m obilization leads to progressive decrease in m u scle m ass, stren gth , an d ten sion based on a decrease o m u scle ber diam eter [10]. Th e collagen bers develop cross-lin ks, w h ich are ollow ed by lessen ed f exibility o ten don s an d ligam en ts. Du rin g im m obilization , cartilage degen eration starts w ith proteoglycan decrease [10]. With im m obilization , th e n orm al eedback system betw een m u scle spin dle an d skin an d join t receptors is also in f u en ced.

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Sen som otor e ects: Fu n ction al dressin g an d ban dagin g w ill resu lt in u n ction in g sen som otor path w ays in m u scles an d join ts. Psych ological e ects: A u n ction al ban dage or bracin g can resu lt in a eelin g o sa ety, especially w ith an xiou s patien ts. Sarm ien to et al rst described u n ction al bracin g in 1977 [13]. His brace con sisted o an terior an d posterior syn th etic h al -sh ells th at w ere xed togeth er w ith velcro straps. Th e redu ced ractu re w as kept in position th rou gh so ttissu e com pression , an d w ith decreasin g sw ellin g, th e brace w as tigh ten ed. Th e prin ciple is com parable to th e h igh stability o a lled plastic soda/ w ater bottle ( ig 3 5 ). Fu n ction al ractu re treatm en t m akes u se o th e biology o ractu re an d so t-tissu e h ealin g. Th e n orm al eedback o th e body, in clu din g th at in itiated by pain , is h elp u l in u n ction al treatm en t.

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Fu n ction al treatm en t is n orm ally an early m obilization th erapeu tic regim e. Th e goal o u n ction al treatm en t is th at th e extrem ity at th e en d o treatm en t recovers m axim al possible u n ction w ith : • Im provem en t o join t u n ction • Proph ylaxis o con traction s • Im proved coordin ation • Stren gth en in g o m u scles an d u n ction • Possibility or en du ran ce train in g • Possibility or train in g o n e an d gross m otor skills.

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In d ica t io n s fo r fu n ct io n a l t re a t m e n t

Fu n ction al treatm en t is especially in dicated in n on operative ractu re care o ractu red lon g bon es. Fractu res o th e clavicle or pediatric ractu res o th e tibia are u rth er in dication s. Fu n ction al treatm en t is also in dicated a ter variou s osteosyn th eses o lon g bon es, ie, m etaph yseal an d articu lar ractu res. At th e n al ch ecku p o every cast, splin t, or orth osis, th e ree m ovem en t o all join ts th at do n ot requ ire im m obilization m u st be possible. Alth ou gh th ere are n u m erou s advan tages o u n ction al n on operative ractu re care, operative ractu re treatm en t is preerred in m an y cou n tries. Th e expen ditu re o tim e an d person n el is n early th e sam e as or operative treatm en t. Fractu re braces or u n ction al treatm en t n eed in dividu ally adapted adju stm en ts by a cast specialist/ orth opedic tech n ician . How ever, h ospitals can earn m ore m on ey by operative ractu re treatm en t th an w ith u n ction al ractu re care. In developin g cou n tries, on th e oth er h an d, m an y patien ts obtain a avorable ou tcom e rom th is low -cost n on operative treatm en t option .

Bio m e c a n ics o f ca s t s ran Se ibe rt, Klaus Dre sing, os Enge le n

Wh en ever an extrem ity is relaxed an d n ot in m otion it is in balan ce. Forces applied to th is extrem ity w ill lead to m ovem en t an d resu lt in m otion , wh ich in tu rn w ill lead to a ch an ge in position . Mech an ics is a scien ce devoted to stu dyin g orces an d th e resu lts o th ese orces. Biom ech an ics is th e im plem en tation o m ech an ical prin ciples in corporated in to th e m u scu loskeletal system an d also pertain s to im m obilized extrem ities in casts [17]. Ph ysician s dealin g w ith im m obilization sh ou ld u n derstan d th ese prin ciples, as th ey are essen tial or th e selection an d application o a splin t or cast. In th e case o ractu res, th ere m ay be an im balan ce betw een th e orces on th e extrem ity resu ltin g in displacem en t o th e di eren t parts o th e ractu red bon e. Th e cau se o th is displacem en t can com e rom th e trau m a itsel , rom direct orce on th e extrem ity, or rom th e leverage o th e in serted m u scles pu llin g on th e ractu re ragm en ts in stead o an in tact bon e [18]. In th eory, a su pport (or a orce) to cou n ter th ese orces is n eeded to stabilize th e broken bon e or th e u n stable join t. Th e w ay to correct th is im balan ce also depen ds on th e am ou n t o orce. For exam ple, th ere is m u ch m ore ten sion on th e variou s ragm en ts in a broken orearm th an in a broken clavicle. Th ere ore, th e n eed or stabilization or im m obilization is m u ch h igh er in a orearm ractu re. Usin g splin ts or casts m ean s u sin g an extern al orce. Stabilizin g on ly tw o poin ts, distally an d proxim ally o th e ractu re, w ill n ot be su cien t or con trol o an gu lation . A th ird poin t is n eeded in order to cou n teract th e orces on th e variou s ragm en ts on ce th e m u scle pu lls. Th e th ree-poin t xation tech n iqu e is n ecessary in order to stabilize or im m obilize a ractu re as th is w ill ach ieve a n ew balan ce betw een th e di eren t ragm en ts ( ig 3 6 ) [19]. As already m en tion ed, th e n ecessary am ou n t o cou n ter orce depen ds on th e am ou n t o orce applied to th e extrem ity. In a orearm ractu re, an above-elbow cast or splin t h as to be applied oth erwise th e resu ltin g orces on th e ragm en ts wou ld exceed th e cou n ter orce provided by th e cast. On th e oth er h an d, a ractu re in th e an kle is so ar rom th e proxim al side o th e tibia or bu la th at a below -kn ee cast w ill su ce to cou n teract th e orces exerted on th e ragm en ts. Th ere is n o n eed to accom m odate th e th ree-poin t prin ciple, as th e resu ltin g orces are cou n teracted by m ean s o th e proxim al tibia or bu la. On e sh ou ld alw ays aim to leave as m u ch m ovem en t as possible, an d i th ere is n o n eed to im m obilize th e proxim al join t it sh ou ld n ot be don e. However, a proxim al ban dage

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, ran Se ibe rt, os Engele n

I n eeded, in clu de join ts in a u n ction al m an n er so th at con tractu re can be preven ted. Exten ded casts, eg, u pper-arm casts or orearm ractu res, sh ou ld on ly stay on or as sh ort a tim e as n ecessary an d be in a u n ction al position (90° elbow f exion ) in order to allow early m otion a ter cast redu ction . Th e sam e applies to lon g leg POP casts or a lower-leg ractu re. As soon as possible, th e cast sh ou ld be exch an ged or a Sarm ien to-like patellar bearin g cast in order to allow kn ee f exion by con trollin g align m en t an d axis o th e lower-leg ractu res. In som e special cases an d ractu res, a Stein m an pin w ill n eed to be in corporated w ith in th e plaster (eg, Stein m an pin in -

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Som etim es, it is also h elp u l to in corporate elastic devices (elastic ban ds or sprin gs) in im m obilizin g splin ts or casts in order to h elp avoid active m otion in th e direction n eedin g protection . For exam ple, a ter su tu re repair o f exor ten don s, active f exion , w h ich pu ts ten sion on ten don s an d su tu res, h as to be avoided du rin g th e rst period a ter su rgery. Th ereore, f exion is ach ieved passively by sprin gs or elastic ban ds w h ile active exten sion / stretch in g o th e n gers is en cou raged in order to allow ten don glidin g an d to avoid adh esion s an d scarin g arou n d th e ten don s. Even th e process o h ealin g w ill be im proved by better circu lation an d orm in g o a n ew brou s ch an n el a ter su rgical open in g o th e f exor ten don sh eath to perm it ten don repair.

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An oth er w ay to stabilize a ractu re in a lon g bon e is to apply a certain type o com pression by m ean s o th e so t tissu es (h ydrau lic e ect) as pu blish ed by Sarm ien to on h is brace tech n iqu es ( or exam ple, see ig 3 4 d ). Th ese tech n iqu es o er th e possibility o leavin g both join ts o th e ractu re (distal an d proxim al) ree. A stabilizin g or im m obilizin g ban dage w ill on ly stabilize or im m obilize i th e prin ciples o m ech an ics an d biom ech an ics h ave been applied properly. It m u st also be ackn ow ledged th at th e design an d application o casts or ractu re treatm en t is an art, passed rom teach er to stu den t. Collected clin ical experien ce in orm s u s o in dication s an d likely resu lts, based u pon ractu re an alysis an d classi cation .

serted in th e calcan eu s in a tibial pilon ractu re). Th is w ill allow you to apply traction w h ile keepin g th e ragm en ts in th e correct position at rst. Special paddin g w ill allow correctin g th e axes du rin g th e rst period o im m obilization an d orm ation o th e rst callu s, w h ich is still f exible en ou gh to allow correction .

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th at is too sh ort or too loose w ill lose its stabilizin g e ect an d w ill lead to m ore leverage, resu ltin g in a loss o redu ction or even a rotation o th e ractu re.

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A special lesson can be learn ed rom Sarm ien to. He m ade u se o th e m u scle pressu re rom th e su rrou n din g m u scles to brin g ractu re ragm en ts in to place by distribu tin g th e pressu re rom th e cast via m u scle activity directly on to th e bon e in order to ach ieve good align m en t. Sarm ien to gain ed great experien ce an d su ccess by bracin g ractu res, w h ich is still a com m on practice today w ith h u m eral sh a t ractu res, an d isolated u ln ar sh a t ractu res. He also reported good resu lts or closed tibial sh a t ractu res, particu larly th ose du e to low er en ergy in ju ries, an d ch aracterized by lesser degrees o displacem en t an d sh orten in g. Today, th e Sarm ien to version o th e below -kn ee cast is still u sed. It partly in corporates th e em oral con dyles, h elpin g con trol rotation , an d, th rou gh good con tact an d m oldin g, im proves ractu re stability (see ch apters 16.8 Sarm ien to (patella ten don bearin g) cast u sin g plaster o Paris an d 16.9 Sarm ien to tibial brace u sin g syn th etic, com bicast tech n iqu e). With th is m eth od, th e tim e n eeded or lon g leg plaster im m obilization o a tibial ractu re is redu ced, an d w eigh t bearin g am bu lation is restored soon er, w ith less depen den ce on cru tch es, an d aster overall reh abilitation .

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ig 3 6 The thre e point principle , using the e xam ple of a traction and re duction cast for the distal radius using POP This fracture pre se nte d with t pical dorsal displace m e nt and angulation of the distal fragm e nt

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Point one dorsal m olde d rim Point two palmar aspe ct, whe re the surge on s palm is situate d Point thre e proximal shaft of the cast whe re the four nge rs are shown

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Principle s of casting

Po s t t re a t m e n t p a t ie n t in fo rm a t io n a n d ca s t c e c Klaus Dre sing

Be ore patien ts are allow ed to leave th e em ergen cy departm en t or doctor‘s su rgery a ter application o a cast, th e doctor m u st in orm th em abou t cast care, recogn ition o poten tial problem s, an d h ow to address th em . Th is in orm ation sh ou ld be discu ssed w ith th e patien t an d an y available caregivers, an d presen ted in w ritten orm . It sh ou ld alw ays in clu de teleph on e n u m bers an d addresses or u rth er advice, prom pt assessm en t, an d an y n ecessary u rgen t care. A copy o th e advice orm , ackn ow ledged by th e patien t, is placed in th e m edical record to con rm th e discu ssion . How ever, docu m en tation alon e can be in su cien t. Patien ts n eed to u n derstan d basic ideas abou t th e com plication s o casts, cast care, an d th at th eir beh avior is an essen tial con tribu tion to th eir ractu re care an d recovery. In som e cases, earlier ollow u p, or atten tion rom visitin g n u rses m ay be w ise. Ca s t ca re in fo rm a t io n

Written in stru ction s in th e patien t’s lan gu age con cern in g ractu re an d cast care an d sa ety are rem em bered better th an in orm ation on ly given orally [20]. Th e in clu sion o illu stration s, pictu res, an d cartoon s to aid th e visu al u n derstan din g o con cepts is advan tageou s [20]. Su ch an in stru ction lea let sh ou ld be provided a ter cast application , w ith in stru ction s regardin g h ow an d w h en to con tact h is/ h er caregivers. An exam ple h as been developed by AOTrau m a an d is in clu ded as an appen dix in th is book an d as a dow n loadable docu m en t rom th e Th iem e w ebsite. Oth er exam ples are also easily ou n d on th e in tern et. Th e m edical in orm ation provided to a patien t sh ou ld address th e ollow in g poten tial problem s an d issu es (a selection ) [21].

Patien t advice an d in orm ation Th e patien t sh ou ld be advised to: • Avoid w earin g jew elry on th e a ected lim b becau se o th e sw ellin g o th e so t tissu es an d th e possibility o pin ch in g or con striction , especially by rin gs on n gers • Rem ove opaqu e n ail varn ish / polish an d arti cial n ger n ails on th e a ected extrem ity in order to allow exam in ation o capillary re ll. Th e patien t sh ou ld be in orm ed abou t th e ollow in g. Pain : • Sign i can tly in creased or u n respon sive pain m ay in dicate seriou s problem s an d sh ou ld be discu ssed prom ptly w ith th e su rgeon or h is / h er represen tative by teleph on e or in person . Sw ellin g: • I th e lim b sw ells, th e cast w ill becom e too tigh t an d cau se in ju ry becau se o in ter eren ce w ith n orm al blood f ow • Th ere cou ld be sw ellin g o th e n gers or toes; n orm al skin color tu rn s to dark red, to blu e, or w h ite. Itch in g (pru ritu s): • Itch in g in side a cast is n ot u n u su al, h ow ever, n oth in g sh ou ld be pu sh ed in to th e cast to “scratch th e itch ” • A vacu u m clean er or (strictly) cold h air dryer m ay be u sed to su ck or blow air th rou gh th e cast, w h ich can relieve itch in g sen sation . Neu ral sign s: • Sen sation cau sed by cast xin g pin s • Sen sory de cits (n u m bn ess, loss o eelin g) • Weakn ess or in ability to m ove n gers or toes • Bu rn in g sen sation s • “Pin s an d n eedles” sen sation . Vascu lar sign s/ sym ptom s: • In orm ation abou t sign s (deep pain in th e cal ) an d sym ptom s o deep ven ou s th rom bosis, w h ich can lead to pu lm on ary em bolism • Skin irritation • Blisters • Ru bbin g • Hu m idity, w etn ess ben eath th e cast as sign s o developin g blisters (bu llae) • Foreign item ben eath th e cast, especially in ch ildren .

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, ran Se ibe rt, os Engele n

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Th e day a ter th e application o a prim ary cast, it is essen tial th at th e patien t is evalu ated by th e su rgeon or an appropriate team m em ber. Th e ollow in g item s sh ou ld be ch ecked:

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• Sw ellin g distal to th e cast • Excessive or ocal pain • In adequ ate blood circu lation – Capillary re ll – Pu lses i available • Motor stren gth • Sen sation • Com partm en t syn drom e sign s – Excessive pain – Tigh t sw ellin g – Passive stretch toleran ce – Redu ced sen sation an d/ or stren gth .

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Cast care/ ractu re care: • Mobilization o n eigh borin g join ts • Movem en t o n gers or toes • Elevation o th e a ected lim b on a pillow in order to h ave a better an d aster redu ction o sw ellin g • (Lim ited) w eigh t bearin g as advised by th e su rgeon , u se o cru tch es • Use o cast sh oes or th e low er extrem ity in order to protect th e cast • Protection again st h u m idity/ w ettin g – No w ettin g th e cast or dippin g in w ater, especially POP, becau se th is can destroy th e cast or disin tegrate th e cast layers – Keep th e cast covered u n der rain y con dition s – Bath in g in stru ction s – I th e POP cast h as becom e w et, a n ew on e sh ou ld be applied – Syn th etic casts are n orm ally resistan t to h u m idity/ dam pn ess bu t th e paddin g u sed is n ot – On ly u se h airdryers, w ith protection again st h eat • Protection rom h eat – Keep a distan ce rom re an d oth er h eat sou rces, becau se th e h eat bu ild-u p can cau se skin irritation an d even bu rn s ben eath th e cast • Protection again st extern al orces or im pact – Th e cast can break or crack i it receives a localized im pact, especially POP casts • Drivin g is n ot perm itted w ith a cast • Risks in volvin g f igh ts w ith casts – In creased risk o th rom bosis w ith leg casts • How to con tact th e ph ysician , an d coverage or rou tin e qu estion s, ollow -u p appoin tm en ts, an d or em ergen cies.

o u t in e ca s t c e c

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Loosen in g o cast: • A ter sw ellin g h as redu ced, th e cast m ay becom e loose an d th e loss o su pport can resu lt in a loss o redu ction an d correct position o th e ractu re ragm en ts • Or in cases o n on com plian ce, th e patien t m an ipu lates or loosen s th e cast.

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An y abn orm alities m u st be docu m en ted an d addressed appropriately. Th e patien t’s u n derstan din g o h is/ h er in ju ry an d care plan , as w ell as ability to cope w ith th e activities o daily livin g, sh ou ld also be review ed an d addressed as n eeded. Depen din g on th e type o ractu re an d body region , an x-ray o poten tially u n stable ractu res or dislocation s sh ou ld be repeated periodically an d com pared w ith th e earlier stu dies, as in dicated by th e gu idelin es o relevan t region al an d n ation al pro ession al societies. By review in g th e x-rays, ph ysician s are able to detect redisplacem en t or u n satis actory align m en t o ractu res an d recom m en d tim ely correction s.

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Principle s of casting

Ca s t

e d gin g

Klaus Dre sing

Du rin g n on operative treatm en t o lon g bon e ractu res, deorm ities can occu r at th e ractu re site. Th is cou ld be th e resu lt o an u n satis actory in itial redu ction , or a su bsequ en t loss o align m en t. De orm ity m u st be con sidered in several plan es an d direction s. Wh ile on e orm m igh t predom in ate in an y given case, de orm ity typically in volves a com bin ation o deviation s rom n orm al align m en t. De orm ities, u su ally described in term s o location o th e distal ragm en t relative to th e proxim al, in volve: • Len gth , u su ally sh orten in g bu t occasion ally distraction alon g th e lon gitu din al axis • Rotation , in tern ally or extern ally, arou n d th e lon g axis o th e bon e • Tran sverse displacem en t, ie, sh i t o th e distal segm en t' s location across a plan e perpen dicu lar to th e lon g axis o th e proxim al segm en t (m edially, laterally, an teriorly, posteriorly, or som e com bin ation th ereo ) • An gu lation , betw een th e axes o distal an d proxim al segm en ts. An gu lation is u su ally iden ti ed an d described w ith th e aid o AP an d lateral x-rays th rou gh th e patien t' s cast. I an gu lation is eviden t on both o th ese 90° opposed view s, th is in dicates th at th e plan e o m axim al an gu lation is betw een th e radiograph ic plan es, an d th at th e tru e an gle o axis deviation is greater th an th at observed on eith er x-ray. For su ch an gu lation to be u n derstood an d corrected, th e su rgeon m u st iden ti y th e plan e o m axim al an gu lation , m easu re th e an gle accu rately, an d m ake an equ ivalen t correction orien ted in th e plan e. Paley discu sses th is as an "obliqu e plan e de orm ity" [22]. Orth opedic tradition h as been to separate an gu lar de orm ities in to th ose observed on th e AP x-rays, called varu s or valgu s, an d th ose on th e lateral xrays, called an tecu rvation (or apex an terior) an d retro or recu rvation (apex posterior). On ly w h en n o de orm ity is eviden t on th e 90° opposed view w ill su ch a de orm ity be com pletely corrected by m an ipu lation in eith er coron al or sagittal plan e. By correctin g an gu lation in th e tru e plan e o de orm ity (eg, properly orien tin g th e direction o cast w edgin g) th e su rgeon is able to ach ieve a straigh t bon e. Relatively sm all de orm ities can be w ell tolerated, an d possibly even n ot n oticed, w ith ou t care u l exam in ation . More sign i can t lon g bon e de orm ities com prom ise u n ction al ou tcom e, m ay be associated w ith posttrau m atic arth ritis, an d can be u n sigh tly, w ith resu ltin g patien t distress. Wh ile de orm ities in an im m atu re skeleton can im prove, i th ey are in th e plan e o m otion o an adjacen t join t, an d i su cien t lim b grow th rem ain s, th ose in skeletally m atu re patien ts are perm an en t w ith ou t su rgical correction . On e o

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th e sign i can t tasks o n on operative ractu re treatm en t is to recogn ize an d correct a sign i can t de orm ity be ore h ealin g progresses to th e poin t th at n on operative realign m en t is n ot possible. Sh orten in g, tran sverse plan e displacem en t, an d sign i can t rotation are h arder to correct w ith ou t su rgery. A h ealin g ractu re rem ain s "ben dable" lon ger w ith a larger tim e w in dow or correctin g an gu lation . Th e ollow in g approach is su ggested or avoidin g excessive de orm ity. Len gth : Lon g bon e ractu res treated n on operatively ten d to h eal, w ith th e am ou n t o overlappin g observed on in itial x-rays (w ith ou t an y applied traction ). I th is overlappin g seem s excessive, m easu res m u st be taken to restore an d m ain tain len gth u n til it is stable (eg, skeletal traction , extern al xation , or in tern al xation ). Rotation : A care u l visu al exam in ation , w ith th e u n in ju red lim b h eld in a position sym m etric to th e on e in th e cast, can be very h elp u l, or exam ple, in assessin g tibial rotation al align m en t. Rotation is n ot easily assessed w ith AP an d lateral x-rays, bu t m ism atch ed diam eter o th e ractu re en ds, an d variou s speci c lan dm arks or each lon g bon e, su ggest m alrotation . Sign i can t m alrotation sh ou ld be iden ti ed as soon as possible a ter th e in itial de n itive cast is applied. I it can n ot be corrected by rem an ipu lation , early su rgical correction is advisable. Precise m easu rem en t o rotation al align m en t can be don e w ith f u oroscopic position in g tech n iqu es an d m ore precisely w ith CT scan s. Tran sverse displacem en t: Tran sverse displacem en t is o ten produ ced by overlappin g. By itsel , it poses ew problem s, u n less a gap betw een th e bon e en ds su ggests in terposed so t tissu es. Su ch a n din g sh ou ld su ggest an in creased risk o delayed u n ion , an d perh aps at least a relative in dication or open redu ction an d in tern al xation . An gu lation : Sm all degrees o an gu lation are qu ite acceptable or m an y ractu res treated n on operatively. How ever, th ere is a ten den cy or sligh t an gu lation to in crease w ith tim e, especially or ractu res in a m etadiaph yseal location w h ere a cast m igh t n ot o er good con trol o th e sh orter bon e segm en t. Patien ts w ith presu m ably acceptable an gu lation m u st be w atch ed closely in order to provide a tim ely correction sh ou ld th e an gu lation in crease. Correction o an gu lar de orm ity m ay n ot on ly be possible, bu t easier to m ain tain , i it is don e th rou gh ben dable callu s 2 or 3 w eeks a ter in ju ry, w ith

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, ran Se ibe rt, os Engele n

St e p s fo r ca s t

e d gin g

Th e steps or con du ctin g cast w edgin g are as ollow s: • An alyze th e bon e-axis deviation by x-ray • Plan th e w edgin g procedu re – On plain x-rays, by draw in g th e correction axes on tran sparen t overlay paper – In pictu re arch ivin g an d com m u n ication system s (PACS), by u sin g IT tools • Determ in e th e w edge w ith resu ltin g len gth en in g or sh orten in g – In th e in ter ace o th e m ain ragm en ts – Or m ore distally or proxim ally o th e ractu re zon e – With on e or m ore cu ts • Mark th e an atom ical axis, th e deviation axis, an d th e proposed cu ts in to th e cast w ith a perm an en t elt m arker or w ith sh ort draw in g pin s [24] • Split th e cast as plan n ed – ¾ arou n d th e circu m eren ce o th e cast – Or altern atively, ½ o th e circu m eren ce o th e cast, w ith an addition al sh orter cu t on th e opposite side to avoid lim b len gth alteration s • Redu ce th e ractu re an d realign th e axis – Closin g-w edge cast tech n iqu e - Cu ttin g ou t a ¾ circu m eren tial cast w edge – Open in g-w edge cast tech n iqu e - On e cu t ¾ circu m eren tially an d in terposition o a spacer (piece o w ood or cork) in th e cast gap - Fillin g th e rem ain in g cast gap w ith addition al paddin g m aterial in order to avoid gap edem a • Close th e gap w ith POP or syn th etic cast m aterial applied circu larly over th e gap • Con du ct x-ray con trols • Provide relevan t patien t in orm ation .

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Th e process requ ires th at you m ark th e axes o th e tw o m ain ragm en ts. Firstly, th e an atom ical axis is m arked on th e xray (as an exam ple, th e an terior/ posterior (AP) an atom ical axis o th e tibia is sh ow n in ig 3 ). Secon dly, th e deviation axis is determ in ed. Th e axes w ill n ot m eet in on e lin e, in stead th ey w ill in tersect. Th is in tersection o th e tw o lin es is called th e “cen ter o an gu lation ”.

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Norm ally, an esth esia du rin g th e cast w edgin g process is n ot recom m en ded [2] as it in creases th e dan ger o h arm in g th e u n derlyin g skin an d so t tissu es. Cast w edgin g h as been sh ow n to correct an gu lation o < 5° or ractu res w ith isolated varu s, valgu s, or apex an terior de orm ities w ith a 90% su ccess rate [23].

To determ in e th e m alalign m en t o th e an atom ical axis a ter th e trau m a or treatm en t, a clin ical evalu ation o m ovem en t as w ell as an an alysis o th e axis in th e x-ray is requ ired. At th e con clu sion o a su rgical ractu re redu ction an d f xation , assessm en t o ractu re align m en t, in clu din g passive ran ges o m otion , is rou tin e be ore th e patien t is aw aken ed. In n on operative ractu re treatm en t, th is clin ical ch ecku p is lim ited becau se o ten th e n eigh borin g join ts are im m obilized. Th ere ore, x-ray con trols an d an alysis o th e axis are requ ired.

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Wedgin g is an elegan t w ay to correct an gu lar de orm ity. How ever, on ly ractu res im m obilized in u ll casts are su itable or th is m eth od. Cast w edgin g allow s con trolled correction w ith ou t th e n eed or recastin g bu t can poten tially cau se n erve palsy or skin irritation . Böh ler proposed w edgin g or an gu lar de orm ities o less th an 15–20° [2].

n a l s is o f m a la lign m e n t

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eith er m an ipu lation du rin g a cast ch an ge or w ith w ellplan n ed cast w edgin g.

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ig 3 The anatom ical axis of the tibia is de ne d as the line from the middle of the tibial plate au to the m iddle of the talus AP vie w

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a lgu s a n gu la t io n

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I a valgu s (in w ard an gled) de orm ation is diagn osed, th e axes o th e tw o m ain ragm en ts are m arked, an d th e an gle betw een th e axes (called th e “deviation an gle” or α) is m easu red ( ig 3 a ). Th is an gle is th en tran s erred to th e ractu re ( ragm en ts) plan es (becom in g th e “correction an gle” or α’) ( ig 3 ).

Clo s in g

e d ge ca s t t e c n i u e

To treat a valgu s an gu lation u sin g th e closin g-w edge cast tech n iqu e, th e cast is cu t 2/ 3 o th e w ay arou n d th e con vex side o th e m ain ractu re lin e. Th e correction an gle ( α’) determ in es th e len gth o w edge to be cu t ou t o th e cast (len gth a–b) as w ell as th e tw o cu ttin g plan es (cu t I an d II) ( ig 3 a ). Th ese cu ttin g lin es in tersect at th e “cen ter o cu ttin g” lateral to th e ibu la. Th e cen ter o an gu lation (COA) is position ed close to th e edge. A ter rem oval o th e w edge o cast (len gth a–b), th e cast is closed m edially an d th e an atom ical axis is restored ( ig 3 ). Th is m u st be ollow ed w ith closin g o th e gap by applyin g POP or syn th etic cast m aterial over th e gap, circu larly arou n d th e cast.

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Principle s of casting

Intersection of the two axes center of angulation

Wh en u sin g th e closin g-w edge cast tech n iqu e th e leg w ill sh orten w h en closin g th e w edge. Ch ecku p w ith a n ew x-ray is m an datory.

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Cut II

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Center of cutting

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Cut I

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algus angulation in an AP sche m atic x ra

a The anatom ical axis blac and the de viation axis blue are m ar e d The angle be twe e n the anatom ical and de viation axe s is m e asure d the de viation angle α The de viation angle is transfe rre d to the m e dial aspe ct of the cast be com ing the corre ction angle α’

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ig 3

b a

Closing we dge cast te chni ue

a The corre ction angle α’ de te rmine s the le ngth to be cut out of the cast as we ll as the two cutting plane s The se line s inte rse ct in the ce nte r of cutting late ral to the bula re d dot Once the cast we dge is re m ove d, the cast is close d m e diall in the dire ction of the gre e n arrows and the anatom ical axis is re store d

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, ran Se ibe rt, os Engele n

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To treat a valgu s an gu lation u sin g th e open in g-w edge cast tech n iqu e, th e cast is cu t 2/ 3 o th e w ay arou n d th e con cave side. Th e correction an gle ( α’) determ in es th e len gth th e cast m u st be spread apart (len gth a–b) ( ig 3 a ).

Wh en u sin g th e open in g-w edge cast tech n iqu e th e leg w ill len gth en w h en open in g th e w edge. Ch ecku p w ith a n ew x-ray is m an datory.

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A cast spreader is in serted in to th e n ew ly created space. Th e cast is spread an d a cork or w ood spacer o len gth a–b is in serted. Th e an atom ical axis is restored ( ig 3 ). Th e

rem ain in g cast gap is lled w ith addition al paddin g m aterial in order to avoid gap edem a, an d th e gap is closed an d stabilized w ith POP or syn th etic cast m aterial applied over th e gap circu larly ( ig 3 ).

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Cast material Cork Padding

Widening with a plaster cast spreader and insertion of a spacer

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a b

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Padding

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Ope ning we dge cast te chni ue

The cast is cut once on the concave side The corre ction angle α’ de te rm ine s the distance the cast m ust be spre ad apart le ngth a b The cast is spre ad and a space r of le ngth a b orange line is inse rte d to re store the anatomical axis

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Cork

b ig 3

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Closing the gap

a The cast gap is lle d with additional padding m ate rial in orde r to avoid gap e de m a

The gap is close d and stabili e d with POP or s nthe tic cast m ate rial applie d ove r the gap circularl

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Principle s of casting

A com parison o th e open in g-w edge an d closin g-w edge cast tech n iqu es or correction o a valgu s an gu lation is sh ow n in ig 3 . e d gin g

it o u t le n g t

c a n ge o f t e lim

I n o alteration o lim b len gth is in dicated, th e cen ter o th e w edge is placed in th e m iddle o th e cast, th e rst cu t is don e on th e con vex side, an d a su pplem en tary sh ort cu t is don e h orizon tally on th e opposite side. Wh en spreadin g th e cast in cision on th e con vex side w ith a plaster cast spreader, n o len gth en in g or sh orten in g w ill occu r ( ig 3 3 ).

a ru s a n gu la t io n

I a varu s (ou tw ard an gled) de orm ation is diagn osed, th e axes o th e tw o m ain ragm en ts are m arked. Th e deviation an gle betw een th e axes is m easu red an d tran s erred to th e ractu re ( ragm en ts) plan es, becom in g th e correction an gle ( ig 3 4 ).

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Cut II

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Closing wedge

ig 3 Com parison of ope ning we dge and closing we dge cast te chni ue s in valgus angulations The inte rse ction points of the angle s are locate d m e diall and late rall

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ig 3 3 Cast we dging without le ngthe n ing or shorte ning of the lim b The de viation angle α is transfe rre d to the cutting are a α’ on the m e dial aspe ct of the cast

ig 3 4 arus angulation in an AP sche m atic x ra The anatom ical and de viation axe s are mar e d, the varus de viation angle is m e asure d α , and the angle is the n transfe rre d to the cutting are a on the late ral aspe ct of the cast α’

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

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Klaus Dre sing, ran Se ibe rt, os Engele n

Clo s in g

e d ge ca s t t e c n i u e

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To treat a varu s an gu lation u sin g th e closin g-w edge cast tech n iqu e, th e cast is cu t on th e con cave side alon g th e ractu re lin e. Th e correction an gle determ in es th e len gth o w edge to cu t ou t (len gth a–b) as w ell as th e tw o cu ttin g plan es ( ig 3 5 a ).

e d ge ca s t t e c n i u e

To treat a varu s an gu lation u sin g th e open in g-w edge cast tech n iqu e, th e cast is cu t on th e con vex side ( ig 3 6 a ). Th e cast is spread (len gth a–b) an d a spacer is in serted ( ig 3 6 ). Th e rem ain in g cast gap is lled w ith addition al paddin g m aterial in order to avoid gap edem a an d th e gap is closed an d stabilized. Th e bon e w ill len gth en w h en open in g th e w edge an d a ch ecku p w ith a n ew x-ray is m an datory.

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A ter rem oval o th e w edge, th e cast is closed ( ig 3 5 ). Th e leg w ill sh orten w h en closin g th e w edge an d a ch ecku p w ith a n ew x-ray is m an datory.

p e n in g

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Authors

Cut II Cut I

a b

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ig 3 5 a angulation

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The closing we dge cast te chni ue to tre at a varus

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ig 3 6 a angulation

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I n o alteration o lim b len gth is in dicated, th e cen ter o th e w edge is placed in th e m iddle o th e cast. Th e rst cu t is don e on th e con cave side an d a su pplem en tary sh ort cu t is don e h orizon tally on th e opposite side. Wh en spreadin g th e cast in cision on th e con cave side w ith a cast spreader, n o len gth en in g or sh orten in g w ill resu lt ( ig 3 ).

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n t e cu r va t io n a n gu la t io n

An an tecu rvation (apex an terior) an gu lation occu rs w h en th ere is a sligh t degree o orw ard cu rvatu re o a ractu red diaph yseal bon e. Again , tw o cast w edgin g m eth ods are possible, ie, closin g-w edge or open in g-w edge cast tech n iqu e. Th e axes o th e tw o m ain ragm en ts are m arked, an d th e an gle betw een th e axes is m easu red an d tran s erred (see ig 3 an d ig 3 .

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ig 3 The anatom ical axis of the lowe r lim b m ar e d in the late ral sche m atic x ra vie w

ig 3 Ante curvation angulation The anatom ical and de viation axe s are m ar e d The de viation angle α de te rm ine s the corre ction angle α’

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

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To treat an an tecu rvation an gu lation u sin g th e closin g-w edge cast tech n iqu e, th e correction an gle ( α’) in dicates th e len gth o th e w edge to be cu t rom th e cast (len gth a–b) as w ell as th e tw o cu ttin g plan es (cu t I an d II) ( ig 3 3 a ). Th ese lin es in tersect dorsally at th e cen ter o cu ttin g.

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Authors

To treat an an tecu rvation an gu lation u sin g th e open in gw edge cast tech n iqu e, a dorsal w edge is in serted an d lled a ter th e correction ( ig 3 3 ). A cast spreader is in serted w ith in th e dorsal cu t an d open ed to th e len gth a–b correspon din g to th e correction an gle ( α’). Th e in tersection lin e o th e tw o plan es is ven tral to th e tibia.

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Th e w edge is cu t ou t o th e an terior aspect o th e cast an d th e an atom ical axis is restored by closin g o th e w edge ( ig 3 3 ).

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Wh en ever a rare retrocu rvation (apex posterior) an gu lation is observed, a correction w ith cast w edgin g m ay be in dicated. Th e axes o th e tw o m ain ragm en ts are m arked, an d th e an gle betw een th e axes is m easu red an d tran s erred. 6

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In th e closin g-w edge cast tech n iqu e, a w edge on th e dorsal aspect o th e cast is cu t ou t ( ig 3 3 ). A ter an alysis o th e deviation , a wedge is cu t ou t o th e dorsal aspect o th e cast (len gth a–b) correspon din g to th e correction an gle ( α’). Th e in tersection lin e o th e tw o plan es is ven tral to th e tibia. Th e an atom ical axis is restored by closin g o th e w edge.

p e n in g

e d ge ca s t t e c n i u e

In th e open in g-w edge cast tech n iqu e, a w edge on th e ven tral aspect o th e cast is rem oved ( ig 3 33 ). A ter an alysis o th e deviation , an in cision is cu t on th e ven tral aspect o th e cast an d w iden ed w ith a cast spreader (len gth a–b) correspon din g to th e correction an gle ( α’). Th e in tersection lin e o th e tw o plan es is dorsal to th e tibia. A spacer is in serted w ith in th e gap an d th e rem ain in g gap is lled w ith paddin g an d closed w ith POP or syn th etic cast m aterial.

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ig 3 3 a The closing we dge cast te chni ue to tre at a re trocur vation angulation

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Authors

Su m m a r

Klaus Dre sing, ran Se ibe rt, os Enge le n 3

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• Splin ts an d casts are typically m ade o tw o types o m aterial: plaster o Paris kn ow n as POP; or rigid or sem irigid syn th etic • Fu n ction al treatm en t, w h ich en cou rages progressive protected u se o a ractu red lim b, prom otes recovery an d ractu re h ealin g, w h ile lim itin g disu se atroph y, w eakn ess, an d join t sti n ess; it o ten in volves th e u se o ractu re braces design ed to allow som e join t m otion an d w eigh t bearin g • Malalign m en t or ractu re redisplacem en t can develop du rin g n on operative ractu re treatm en t, an d m u st be corrected i it is severe en ou gh to com prom ise resu lts • An gu lation o a ractu re im m obilized in a u lly circu m eren tial cast can be corrected by cast w edgin g, in w h ich a section o cast is cu t at a certain an gle an d rem oved, th e de orm ity is straigh ten ed, an d th e cast is repaired • Patien ts n eed to be u lly in orm ed abou t th e variou s treatm en ts bein g u n dertaken both be ore an d a ter treatm en t; th e patien t’s u n derstan din g o an d level o com plian ce w ith direction s can eith er su pport or delay th e h ealin g process.

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• Fractu res treated n on operatively h eal in directly, th rou gh th e reactive, reparative, an d rem odelin g ph ases, w ith callu s th at becom es n ew w oven bon e • Direct bon e h ealin g (osteon al rem odelin g) on ly occu rs w ith absolu tely stable su rgical xation • Fractu res th at h ave n ot h ealed w ith in th e appropriate period o tim e are said to h ave delayed u n ion , an d by six m on th s are experien cin g n on u n ion • Fractu res can be treated n on operatively u sin g castin g as it keeps th e ractu re in a redu ced position by stabilizin g th e ractu re ragm en ts rom th e ou tside • Non operative ractu re care avoids m an y o th e risks an d n an cial costs th at com e w ith su rgery, h ow ever, castin g requ ires in ten sive su rveillan ce, an d can n ot alw ays be recom m en ded • Castin g is e ective n ot ju st to treat ractu res, bu t also postsu rgery, or to treat ligam en t, ten don an d n erve dam age, or in ection • Th e m ajor types o castin g tech n iqu es in clu de: splin ts, w h en u ll im m obilization is n ot requ ired; u lly circu m eren tial casts; split casts, w h ich allow or sw ellin g; an d rem ovable orth oses an d braces

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2. 3.

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u ca s C a m p io n n i re . Th e treatm en t

o ractu res by m obilization an d m assage (1908). Hand Clin. 1996 Feb; 12(1):167–171. B le r . [Treatment of Fractures]. 1st ed. Wien : Wilh elm Mau dr ich ; 1929. Germ an . B le r . Verbandlehre für Schwestern, Helfer, Studenten und Ärzte. Wien : Wilh elm Mau d rich ; 1943. Germ an . ro p p . [Med ical care as ph ysical in ju r y rom th e view poin t o th e law an d ju risd iction ]. Z Arztl Fortbild Qualitatssich. 1998 Oct; 92(8-9):536 – 542. Germ an . ce a B. [ In orm in g th e su rgical patien t. Ref ection s on th e basic law o patien t au ton om y]. Cir Esp. 2005 Feb; 77(2):60 –64. Span ish . u d o lp , ie r o l e r . [Con servative or operative ractu re treatm en t — altern ative in orm ation in relative in d ication s]. Unfallchirurgie. 1986 Feb; 12(1):4 4 –51. Germ an . Ce ro n i , a rt in , e l u m e a u C, e t a l . Decrease o ph ysical activity level in adolescen ts w ith lim b ractu res: an accelerom etry-based activity m on itor stu dy. BMC Musculoskelet Disord. 2011 May 4; 12:87. o lff . [The Law of Transformation of the Bone/Das Gesetz der Transformation der Knochen]. Berlin : Au gu st Hirsch wald; 1892. Germ an .

u r t e r re a d in g Su rge r

16. Sa rm ie n t o , a go rs i B, c , et a l . Fu n ction al bracin g or th e treatm en t o ractu res o th e h u m eral d iaph ysis. J Bone Joint Surg Am. 2000 Apr; 82(4):478 –486. 17. Sc u re n . Working with Soft Cast — a Manual on Semi-rigid Immobilisation. 2n d ed. Borken : 3M M in n esota M in in g & Manu actu rin g; 1994: 9 –29. 18. Sc p e T. [Immobilization Techniques: Theory and Practice]. Reed Bu sin ess in orm ation ; 1993. Du tch . 19. C a rn le . The Closed Treatment of Common Fractures. 4th ed. Un ited Kin gdom . Cam bridge Un iversity Press; 2010. 20. o s s ie n P, Ca re Sm it , a t e s P, e t a l . E cacy o patien t in orm ation con cern in g casts applied post- ractu re. A NZ J Surg. 2012; 82(3):151–155. 21. a rp . Com plication s rom castin g: pit alls an d pearls. A AOS Bulletin. 2005 Dec. 22. Pa le . Principles of Deformity Correction. Berlin : Sprin ger Verlag; 2002. 23. e lls , ve r , osal ar , e t a l. Cast wedgin g: a “ orgotten ” yet pred ictable m eth od or correctin g ractu re de orm ity. University of Pennsylvania Orthopaedic Journal (UPOJ). 2010; 20:113 –116. 24. o lm a n , a vie s , Sco t t . Fractu re localisation or cast wedgin g. Ann R Coll Surg Eng. 2009 Nov; 91(8):714.

Klaus Dre sing, ran Se ibe rt, os Enge le n

e fe re n ce Castin g. Colton CL,

Sch atzker J, Tra ton P (eds). AO Fou n dation . Available at h ttp:// w w w. aosu rger y.org. [Accessed Ju ly 2011].

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9. Ce ro n i , a r t in , e l u m e a u C, e t a l . E ects o cast-m ediated im m obilization on bon e m in eral m ass at variou s sites in adolescen ts w ith lower-extrem ity ractu re. J Bone Joint Surg Am. 2012 Feb 1; 94(3):208 –216. 10. Cu la v , Cla r C , e rrile e s . Con n ective tissu es: m atrix com position an d its relevan ce to ph ysical th erapy. Phys Ther. 1999 Mar; 79(3):308 –319. 11. a n ge r N, n ggi , lle r N , e t a l . E ects o lim b im m obilization on brain plasticity. Neurology. 2012 Jan 17; 78(3):182 –188. 12. Sa rm ie n t o . A u n ction al below-th ek n ee brace or tibial ractu res: a report on its u se in on e hu n dred an d th irty- ve cases (1970). J Bone Joint Surg Am. 2007 Sep; 89 Su ppl 2 Pt.2:157–169. 13. Sa rm ie n t o , in m a n PB, a lvin , et a l . Fu n ction al bracin g o ractu res o th e sh a t o th e hu m eru s. J Bone Joint Surg Am. 1977 Ju l; 59(5):596 –601. 14. Sa rm ie n t o , a t t a . Fractu res o th e m iddle th ird o th e tibia treated w ith a u n ction al brace. Clin Orthop Relat Res. 2008 Dec; 466(12):3108 –3115. 15. Sa rm ie n t o , a t t a . Fu n ction al treatm en t o closed segm en tal ractu res o th e tibia. Acta Chir Orthop Traumatol Cech. 20 08 Oct; 75(5):325 –331.

e d i TP, Bu c l

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o ra n C

AO Principles of Fracture Management. 2n d ed. Vol 1. Stu ttgart: Th iem e; 2007: 276 –279

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

an Philipp Sch ttrumpf

4

Thrombosis proph laxis an Philipp Sch ttrumpf

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Author

an Philipp Sch ttrumpf

Proph ylaxis attem pts to m odi y on e or m ore o th ese actors, prim arily stasis an d h ypercoagu lability. Th e in ciden ce o sym ptom atic deep vein th rom bosis in th e gen eral pu blic is 90–130 per 100,000 in h abitan ts [1, 2]. Several actors clearly in crease th e risk o VTE, n otably older age, m align an cy, prior VTE, am ily h istory o VTE, an d obesity. Th e prevalen ce o VTE in th e absen ce o proph ylaxis is particu larly sign i can t in som e categories o orth opedic an d trau m a patien ts, or exam ple, 40–80% a ter m u ltiple trau m a an d 40–60% a ter h ip ractu re or total h ip/ kn ee replacem en t [3, 4]. Th e requ en cy o VTE in im m obilized patien ts (cast or splin t) w ith isolated low er-extrem ity in ju ries or orth opedic su rgery is less w ell establish ed. Th ere is som e eviden ce th at patien ts w ith m ore proxim al low erextrem ity in ju ries, at th e kn ee or above, carry a h igh er risk [4]. Ettem a et al estim ated th at, w ith ou t an y proph ylaxis, approxim ately 17% o patien ts w ith ou t obviou s risk actors w ou ld develop VTE [5]. Healy reported a 6.3% rate o sym ptom atic VTE even ts in 208 u n proph ylaxed patien ts w ith Ach illes ten don ru ptu res [6]. Available data, su m m arized in a review by th e Am erican College o Ch est Ph ysician s reports a risk o sym ptom atic deep vein th rom bosis (DVT) o 24 per 1,000 an d 3 per 1,000 or n on atal pu lm on ary em bolism (2.7% overall) am on g im m obilized patien ts in th e con trol grou ps o ran dom ized trials o an ticoagu lation [4].

e p i n i

Patien ts w ith redu ced m obility, eith er du e to a low er-extrem ity in ju ry or su rgery, are gen erally con sidered to carry an in creased risk o in cu rrin g ven ou s th rom boem bolic disease. Th ere ore, patien ts requ irin g im m obilization du e to a low er-extrem ity sprain , ractu re, or ten don ru ptu re, regardless o w h eth er th ey are treated w ith or w ith ou t su rgery, sh ou ld be con sidered or ven ou s th rom boem bolism proph ylaxis. Cau sation o ven ou s th rom boem bolic disease (VTE) is still th ou gh t to be related to Virch ow ’s triad o actors: • Ven ou s stasis • En doth elial in ju ry • Hypercoagu lability.

Th e decision or or again st VTE proph ylaxis as w ell as its speci c orm sh ou ld best be based u pon th e ration al assessm en t o risk or each in dividu al patien t. Un ortu n ately, experts h ave n ot yet com e to agree on h ow to assess th e risks o VTE, n or u pon th e validity o available assessm en t tools. Neverth eless, su rgeon s still h ave to con sider both th e risks o VTE an d o poten tial preven tive m easu res, alon g w ith th e e ectiven ess o variou s proph ylactic regim en s, in order to o er a ration al recom m en dation or VTE proph ylaxis or each patien t.

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Tosetto et al iden ti ed prior h istory o su per cial ph lebitis, obesity, an d sm okin g as sign i can t risk actors or patien ts w ith su rgery or trau m a [7]. Fam ily h istory or oral con traceptive u se w ere less associated in th ese patien ts, h ow ever, th e presen ce o tw o or m ore risk actors in creased th e risk o VTE. In th is con text, th e presen ce o h ypercoagu lability [8] as w ell as th e presen ce o m align an cy [9] are also w orth m en tion in g. In th e absen ce o a reliable an d u n iversally accepted algorith m , it rem ain s ch allen gin g or su rgeon s to ch oose th e m ost appropriate proph ylactic regim en or a given patien t th at h as to be im m obilized or low er-extrem ity in ju ry or orth opedic su rgery. How ever, be ore speci c recom m en dation s or selected situ ation s are presen ted, di eren t option s or VTE proph ylaxis are review ed accordin g to tw o m ain categories: • Non ph arm acological, an d • Ph arm acological.

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Dru g- ree m easu res or th rom bosis proph ylaxis—ph ysical th erapy, m ovem en t, active an kle exercises (cal m u scle pu m p), an d pn eu m atic com pression th erapy—are discu ssed in th is topic.

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clin ical settin gs du e to logistical problem s an d h igh costs, th e literatu re does su pport its e ectiven ess both w h en u sed aith u lly as directed [11] as well as, w ith addition al ben e ts, w h en u sed togeth er with an tith rom botic m edication [4].

3

Wh ile ollow in g appropriate care or th eir in ju ries, patien ts sh ou ld be m obilized as early as possible in order to stim u late th e cardiovascu lar system an d th ereby in crease th e blood f ow w ith in th e m u scles an d so t tissu es o th e low er extrem ities. Su pervised ph ysical th erapy or both in ju red an d in tact body region s sh ou ld be part o th is program . All patien ts sh ou ld be en cou raged to learn appropriate exercises an d practice th em on th eir ow n betw een orm al th erapy session s. Prior to elective su rgery, patien ts can even be train ed in appropriate postoperative exercises.

P a rm a co lo gica l p ro p

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Th e adm in istration o an y m edication to preven t VTE is an addition al step, beyon d th e n on ph arm acological m easu res discu ssed above, w h ich sh ou ld alw ays be u sed in order to redu ce th e requ en cy o th rom boem bolic com plication s. It seem s to be apparen t th at addin g ph arm acological proph ylaxis to th e m ech an ical m eth ods, w h ich are gen erally ree o com plication s, w ou ld provide m ore e ective VTE preven tion . Neverth eless, con rm atory eviden ce o sa ety an d e ectiven ess is still requ ired. As yet, th is is n ot gen erally available, especially or low er-extrem ity in ju ries.

o ve m e n t ca lf m u s cle p u m p

Resu m in g “n orm al” ph ysiological gait or m ovem en t m ay be th e best an d easiest orm o VTE proph ylaxis. All u n h arm ed body region s m u st be part o th e program , as stated above. As soon as possible a ter in ju ry or elective su rgery, th e u se o th e m u scle pu m p in th e cal sh ou ld begin , w ith active dorsal/ plan tar f exion o th e an kle join t an d toe f exion / exten sion . 3

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Th e u se o static com pression stockin gs deserves rou tin e con sideration . On e exam ple in clu des th rom boem bolic deterren t stockin gs, w h ich h ave a com pression pressu re ratin g o arou n d 18 m m Hg in th e an kle region , an d a decreasin g pressu re gradien t rom distal to proxim al. It is essen tial th at th ese stockin gs t th e patien t correctly, per m an u actu rer’s in stru ction s, an d th at con strictin g w rin kles are avoided. Special con train dication s, in addition to th e n eed or a cast or splin t, in clu de periph eral arterial in su cien cy, severe n eu ropath y, exten sive edem a, an d local in ection or oth erw ise com prom ised tissu es. Th e e ectiven ess o su ch elastic stockin gs, alon e or com bin ed w ith ph arm acologic proph ylaxis, h as been reported [10]. In term itten t pn eu m atic com pression is a u se u l au xilliary device or im m obilized patien ts. At certain tim e in tervals, on e to th ree air ch am ber system s are au tom atically in f ated an d def ated w ith a pressu re o u p to 45 m m Hg. Devices exist or th e en tire low er extrem ity or or th e oot alon e. Som e can even be u sed in side a cast or splin t. Cardiac in su cien cy, local in f am m ation s, in ju ries, an d severe h yperten sion are com m on con train dication s. Alth ou gh in term itten t pn eu m atic com pression (IPC) is n ot u sed requ en tly in

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Ph arm acological proph ylaxis is rou tin ely advised by ph ysician s an d su rgeon s in m an y parts o th e w orld w h en ever a patien t n eeds to be im m obilized or a low er-extrem ity in ju ry. Th is seem s qu ite appropriate or patien ts w ith an eviden tially in creased risk o VTE, particu larly i m u ltiple risk actors are presen t [12]. How ever, ph arm acological proph ylaxis is n ot u n iversally recom m en ded as dem on strated by th e Am erican College o Ch est Ph ysician s (ACCP) An tith robotic Gu idelin es, pu blish ed in Febru ary 2012: “We su ggest n o proph ylaxis rath er th an ph arm acologic th rom boproph ylaxis in patien ts w ith isolated low er-leg in ju ries requ irin g leg im m obilization ” [13]. Th is recom m en dation is based on a m eta-an alysis o m ore th an 1,000 patien ts th at sh ow ed sligh t, bu t n on sign i can t redu ction o sym ptom atic DVT an d n on atal pu lm on ary em bolism (PE), w ith a sligh tly elevated risk o bleedin g even ts w h en low -m olecu lar-w eigh t h eparin proph ylaxis w as com pared w ith “u su al care”. Th e ollow in g dru gs are w idely u sed in th e application o dru g-based VTE proph ylaxis. 3

ce t ls a lic lic a cid a s p irin

Th e u se o aspirin as a sin gle ch em oproph ylactic agen t or VTE is con troversial, th ou gh n ot u n com m on in som e parts o th e w orld. Man y experts con sider its e ectiven ess too low to ju sti y recom m en dation [13–15]. How ever, th e m ost recen t ACCP gu idelin es [16], revised rom prior edition s, n ow in clu de aspirin , even w h en u sed alon e, am on g a list o several ph arm acological option s or VTE proph ylaxis. An addition al recom m en dation su ggests th at aspirin m igh t be less e ective th an low -m olecu lar-w eigh t h eparin (LMWH).

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Low-m olecu lar-weigh t h eparin s are ch em ically derived rom UFH th rou gh depolym erization . A n u m ber o su ch agen ts are available, an d th ey are ph arm acologically distin ct rom on e an oth er [17]. Dru g properties in clu din g dosages an d adm in istration sch edu les are n ot th e sam e. Sin ce LMWH paten ts are n ow expirin g, lower cost gen eric version s will soon becom e available, alon g w ith pressu re to select th e lower cost agen ts. However, in tern ation al an d n ation al organ ization s h ave em ph asized th at LMWHs are n ot equ ivalen t. Sh ared ch aracteristics o LMWHs in clu de lon ger du ration o activity th an UFH, pu rely ren al elim in ation , an d varyin g im m u n ogen ic sim ilarity, wh ich , h ow ever, does n ot preven t th em rom occasion ally cau sin g allergic reaction s or th rom bocytopen ia sim ilar to UFH. Patien ts with acu te or ch ron ic ren al im pairm en t, as w ell as th ose th at are elderly, obese, or very sm all, sh ou ld be con sidered or di eren t dosages or altern ative an tith rom botic agen ts. Heparin -in du ced th rom bocytopen ia is a rare bu t seriou s com plication o both UFH an d LMWH. A past h istory o th is con dition is a con train dication to th e u se o h eparin s. As a gen eral precau tion , platelet cou n ts sh ou ld be obtain ed at th e begin n in g o h eparin adm in istration , an d m on itored regu larly. Th e dru g sh ou ld be stopped i th e platelet cou n t alls below 100,000/ m m 3 . An oth er con cern regardin g an ticoagu lan ts, in clu din g LMWH, is th e associated risk o epidu ral h em atom a a ter spin al or epidu ral an esth esia, an d in th e case o spin al ractu re. A sim ilar con cern is posed by recen t h ead in ju ries. Com parin g th e u se o UFH an d LMWH, th e low er DVT rate an d redu ced bleedin g com plication s a ter orth opedic su rgery, as w ell as th e ease o a sin gle daily in jection an d th e eviden ce su pportin g th e th erapeu tic e ectiven ess o LMWH, m igh t in dicate an advan tage or th e u se o LMWH [14, 18–19]. Th e data on n on operatively treated patien ts is lim ited, bu t n o sign i can t di eren ce between UFH an d LMWH cou ld be ou n d regardin g e ectiven ess an d sa ety [20]. 3 3

Co u m a rin s

War arin (h al -li e 24 h ou rs) an d ph en procou m on (h al -li e 120 h ou rs) are th e m ost com m on vitam in -k an tagon ists o th e cou m arin type, w h ich can be adm in istered orally. Th eir delayed e ect, requ ired blood tests (In tern ation al Norm al-

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t e r a n t ico a gu la n t s

A variety o oth er dru gs (eg, on daparin u x, apixaban , dabigatran , rivaroxaban , an d adju sted-dose vitam in -k an tagon ists) th at in ter ere with coagu lation are occasion ally recom m en ded or u se in orth opedic patien ts [4], bu t little eviden ce is as yet available con cern in g th eir sa ety an d e ectiven ess or patien ts w ith low er-extrem ity in ju ries an d im m obilization .

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Un raction ated h eparin h as a h al -li e o two h ou rs an d is elim in ated in equ al portion s via th e liver an d kidn eys. Un raction ated h eparin (UFH) is typically in jected su bcu tan eou sly tw o or th ree tim es a day or VTE proph ylaxis. Mon itorin g o th e an ticoagu lan t e ect is u n n ecessary [14].

ized Ratio) w ith in dividu ally adju sted dosages, an d relatively h igh risk o bleedin g com plication s resu lts in airly rare u se as rst-lin e VTE proph ylaxis or patien ts w ith isolated low er-leg im m obilization [14].

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In su m m ary, rst-lin e ph arm aceu tical VTE proph ylaxis sh ou ld u su ally in volve LMWH (or UFH). A cou m arin m igh t be con sidered as an altern ative [21–22]. How ever, th e con train dication s, n am ely th e risk o bleedin g an d poten tial h eparin -in du ced th rom bocytopen ia, sh ou ld n ot be orgotten .

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Sp e cific re co m m e n d a t io n s fo r u p p e r o r lo e r e t re m it in u rie s it im m o ili in g t re a t m e n t in a ca s t o r s p lin t

Th is topic gives recom m en dation s or th rom bosis proph ylaxis accordin g to in tern ation al gu idelin es an d u p-to-date literatu re. 4

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In gen eral, im m obilization o th e u pper extrem ity does n ot requ ire an tith rom botic dru gs. Bu t th e patien t’s ow n m ovem en t (eg, o th e n gers, ph ysioth erapy) is advan tagen eou s to decrease sw ellin g o th e so t tissu e. How ever, in in dividu al cases w ith m u ltiple or very sign i can t risk actors, th e addition al u se o an an ticoagu lan t m igh t be in dicated [14]. 4

o e r e t re m it

Plaster cast im m obilization o th e low er extrem ity, especially o th e kn ee an d an kle join t, an d th e in ability to bear w eigh t, is regarded as a m oderate risk or th rom bosis [4]. Con trary to th e u pper extrem ity, th e low er extrem ity requ ires certain m easu res w h en in ju red an d stabilized an d im m obilzed in a cast. Th e m ost e ective m easu res are a m u scle pu m p, w alkin g, an d oth er m ovem en t o th e m u scles, w h ich com press th e vein s du rin g con traction o th e m u scle, th en let th em re ll w ith ven ou s blood du rin g th e sw in g ph ase. Th is con traction an d re llin g allow s th e f ow o blood rom periph ere to cen tral, en su rin g n o stasis o blood in th e

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vein s, an d th ere ore, less dan ger o th rom bosis. An active rollin g m ovem en t o th e oot in itiates an d m ain tain s th is process. Th ere is lim ited eviden ce regardin g th e risk o VTE an d th e e ectiven ess an d sa ety o proph ylactic an ticoagu lation or patien ts im m obilized w ith casts or low er-extrem ity in ju ries or su rgery. On ly ou r in tern ation al gu idelin es m ake recom m en dation s in regard to VTE proph ylaxis or su ch patien ts [12]. Tw o recen t in vestigation s h ave sh ow n th at proph ylaxis w ith LMWH redu ces th e VTE rate du rin g im m obilization o th e low er extrem ities. Ettem a et al (2008) per orm ed a m eta-an alysis (in clu din g 1,456 patien ts rom six ran dom ized stu dies) w h ere th e VTE rate w as redu ced rom 17.1 to 9.6% w ith ou t an y in crease in bleedin g com plication s [5]. Testroote et al (2008) m ade a Coch ran e review w h ere th e VTE rate in patien ts w ith an im m obilizin g plaster cast or a m in im u m period o on e w eek du e to an y sort o leg in ju ry varied rom 4.3–40% w ith ou t an y proph ylaxis. Th ese rates w ere sign i can tly low er w h en LMWH w as given on ce daily [19]. Th e m ost recen t ACCP gu idelin es, based u pon Testroote’s review an d in clu din g an oth er m u lticen ter stu dy, repeated th e m eta-an alysis an d con clu ded, as m en tion ed above, th at th ere w as in su cien t eviden ce to establish th e ben e t o th rom boproph ylaxis in th e en rolled patien ts. How ever, it is im portan t to recogn ize th at h igh er-risk patien ts w ere exclu ded rom th ese stu dies.

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Su m m a r

• Follow in g low er-extrem ity in ju ry or su rgery, patien ts w ith redu ced m obility carry an in creased risk o ven ou s th rom boem bolic disease • Every patien t sh ou ld be m obilized as early as possible in accordan ce w ith th e exten t an d pattern o th e in ju ry • Th e aim is to ach ieve at least partial w eigh t bearin g o > 15–20 kilogram s an d a ran ge o m otion in th e u pper an kle join t o 20° (rollin g m otion in th e low er an kle join t an d activation o m u scle pu m p in th e cal ); exclu sion o w eigh t bearin g sh ou ld be avoided, i possible • Proph ylaxis again st ven ou s th rom boem bolism con sists o gen eral n on ph arm acological m easu res w ith addition al dru g-based proph ylaxis, at least or patien ts w ith in creased risk o VTE.

Kn ow ledge abou t risks an d preven tion o VTE in patien ts w ith low er extrem ity casts is still grow in g an d, th u s, gu idelin es are likely to evolve accordin gly. Region al di eren ces in practice are u n derstan dable an d sh ou ld be taken in to con sideration by practition ers. Based on presen t kn ow ledge, it seem s m ost appropriate to apply n on ph arm acological proph ylaxis to th e exten t perm itted by th e patien t’s in ju ries [14]. Patien ts ju dged to h ave elevated risk o VTE sh ou ld be con sidered can didates or dru g-based proph ylaxis, w ith LMWH gen erally bein g th e rst ch oice. I u sed, su ch dru gs sh ou ld be con tin u ed u n til th e cast or splin t h as been rem oved an d partial w eigh t bearin g o > 20 kilogram s an d a ran ge o m otion in th e u pper an kle join t o > 20° h as been ach ieved [23–24].

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

an Philipp Sch ttrumpf

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Author

12. St ru i

u ld e r C, t t e m a B, e r e e n CC, e t a l . Com parin g

con sen su s gu idelin es on th rom boproph ylaxis in orth opedic su rgery. J Thromb Haemost. 2010 Apr; 8(4):678 –683. 13. u o , Sp ro p o u lo s C. Th e eigh th Am erican college o ch est ph ysician s gu idelin es on ven ou s th rom boem bolism preven tion : im plication s or h ospital proph ylaxis strategies. J Thromb Thrombolysis. 2011 Feb; 31(2):196 –208. 14. n c e , a a s S, Sa u e rla n d S, e t a l . [S3-Gu idelin e: Prophylaxis o ven ou s th rom boem bolism (VTE)]. Vasa. 2009; 38(S76):1–131. Germ an . 15. n t ip la t e le t Tria lis t s Co lla o ra t io n . Collaborative overview o ran dom ised trials o an tiplatelet th erapy-III: Redu ction in ven ou s th rom bosis an d pu lm on ar y em bolism by an tiplatelet proph ylaxis am on g su rgical an d m edical patien ts. BMJ. 1994 Jan 22; 308:235 – 246. 16. m e rica n Co lle ge o f C e s t P s icia n s

it ge ra ld

B, Bro o e n t a l , r, e t a l . A m eta-an alysis

o th rom boem bolic proph ylaxis ollow in g elective total h ip arth roplasty. J Bone Joint Surg Am. 2000 Ju l; 82-A(7):929 –938. 22. o d e ric P, e rris , ils o n , e t a l . Towards eviden ce-based gu idelin es or th e preven tion o ven ou s th rom boem bolism : system atic review s o m ech an ical m eth ods, oral an ticoagu lation , dextran an d region al an aesth esia as th rom boproph ylax is. Health Technol A ssess. 2005 Dec; 9(49):1–78. 23. is e le , re ge r , e i e r t , e t a l . Am bu latory preven tion o th rom bosis in trau m atology. Unfallchirurg. 2001 Mar; 104(3):240 –245. 24. is e le , e ic e r t , re n , e t a l . Th e e ect o partial an d u ll weigh t-bearin g on ven ou s retu rn in th e lower lim b. J Bone Joint Surg Br. 20 01 Sep; 83(7):1037–1040.

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In term itten t pn eu m atic com pression an d deep vein th rom bosis preven tion . A m eta-an alysis in postoperative patien ts. Thromb Haemost. 2005 Dec; 94(6):1181–1185.

21. re e d m a n

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, u c e r N, e t a l .

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1. Na e s s I , C ris t ia n s e n SC, o m u n d s t a d P, e t a l . In ciden ce an d m ortality o ven ou s th rom bosis: a popu lation -based stu dy. J Thromb Haemost. 2007 Apr; 5(4):692 –699. 2. it e , o u , u rin S, e t a l . E ect o eth n icity an d gen der on th e in ciden ce o ven ou s th rom boem bolism in a diverse popu lation in Cali orn ia in 1996. Thromb Haemost. 20 05 Feb; 93(2):298 –305. 3. St e in P , Be e m a t , ls o n . Tren ds in th e in ciden ce o pu lm on ary em bolism an d deep ven ou s th rom bosis in h ospitalized patien ts. Am J Cardiol. 2005 Ju n 15; 95(12):1525 –1526. 4. a lc t t e r , ra n cis C , o a n s o n N , e t a l . Preven tion o VTE in orth oped ic su rgery patien ts: An tith rom botic Th erapy an d Preven tion o Th rom bosis, 9th ed: Am er ican College o Ch est Ph ysician s Eviden ce-Based Clin ical Practice Gu idelin es. Chest. 2012 Feb; 141(2 Su ppl):e278S–e325S. 5. t t e m a B, o lle n B , e r e e n CC, e t a l . Preven tion o ven ou s th rom boem bolism in patien ts w ith im m obilization o th e lower extrem ities: a m eta-an alysis o ran dom ized con trolled trials. J Thromb Haemost. 2008 Ju l; 6(7):1093 –1098. 6. e a l B, Be a s le , e a t e ra ll . Ven ou s th rom boem bolism ollow in g prolon ged cast im m obilisation or in ju r y to th e ten do Ach illis. J Bone Joint Surg Br. 2010 May; 92-B (5):646 –650. 7. To s e t t o , re a t o , o d e g ie ro . Prevalen ce an d risk actors o n on - atal ven ou s th rom boem bolism in th e active popu lation o th e VITA Project. J Thromb Haemost. 2003 Au g; 1(8):1724 – 1729. 8. u , o e r t s o n , a n g o rn e P, e t a l . Oral con traceptives, h orm on e replacem en t th erapy, th rom boph ilias an d risk o ven ou s th rom boem bolism : a system atic review. Th e Th rom bosis: Risk an d Econ om ic Assessm en t o Th rom boph ilia Screen in g (TREATS) Stu dy. Thromb Haemost. 2005 Ju l; 94(1):17–25. 9. Blo m , o gge n C , s a n t o S, e t a l . Malign an cies, proth rom botic m u tation s, an d th e risk o ven ou s th rom bosis. JA MA. 2005 Feb 9; 293(6):715 –722. 10. m a ra giri S , e e s T . Elastic com pression stock in gs or preven tion o deep vein th rom bosis. Cochrane Database Syst Rev. 2000; (3):CD001484.

vid e n ce Ba s e d Clin ica l Pra ct ice u id e lin e s e d . An tith rom botic

Th erapy an d Preven tion o Th rom bosis. 9th ed. Chest. 141(2 Su ppl). (On lin e articles on ly). [Accessed 2011]. 17. e rli , ro ce B. Ph arm acological an d clin ical d i eren ces between lowm olecu lar-weigh t h eparin s: im plication s or prescribin g practice an d th erapeu tic in terch an ge. P T. 2010 Feb; 35(2):95 –105. 18. o c , ie gle r S, Bre it s c e rd t , e t a l . Low m olecu lar weigh t h eparin an d u n raction ated h eparin in th rom bosis proph ylaxis: m eta-an alysis based on origin al patien t data. Thromb Res. 2001 May 15; 102(4):295 –309. 19. Te s t ro o t e , St igt e r , d e is s e r C, e t a l . Low m olecu lar weigh t h eparin or preven tion o ven ou s th rom boem bolism in patien ts w ith lower leg im m obilization . Cochrane Database Syst Rev. 20 08 Oct 8;(4). 20. is m e t t i P, a p o r t e Sim it s id is S, Ta rd B, e t a l . Preven tion o ven ou s th rom boem bolism in in tern al m ed icin e w ith u n raction ated or low-m olecu larweigh t h eparin s: a m eta-an alysis o ran dom ised clin ical trials. Thromb Haemost. 2000 Jan ; 83(1):14 –19.

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

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ogistics and resources in the cast room Klaus Dre sing, os Enge le n

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Ca s t ro o m fe a t u re s a n d fa cilit ie s Cast room si e alls and floor Ene rg and wate r suppl , and waste disposal Cast room lighting Surgical e xam ination lam ps e ntilation, air conditioning, and dust e xtraction Traction e xte nsion s ste m Storage room Docum e ntation, acce ss to patie nt re cords, x ra vie wing station

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Ca s t ro o m e u ip m e n t Storage space for cast m ate rials for dail usage Plaste r and cast cart trolle Mobile cast table Im age inte nsifie r Stool for surge on or cast te chnician Cushions and support for e xtre m itie s Instrum e nts

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a in t e n a n ce Cast te chnician Assistance during casting

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Authors

Klaus Dre sing, os Engele n

Today, in m an y h ospitals, th e cast room is n ot u sed exclu sively or th e application o plaster or syn th etic casts bu t also or th e application o ban dages an d orth oses. Orth oses are o ten cu stom -m ade by a cast tech n ician , or occasion ally, by oth er sta . Th ese tech n ician s are train ed to treat

e p i n i

Th e m odern cast room (or plaster room ) is situ ated in proxim ity to th e em ergen cy or operatin g departm en t. In som e settin gs, th e cast room m ay be closer to th e operatin g room (OR) or th e in patien t w ards th an to th e em ergen cy departm en t (ED). Som etim es, th ere m ay even be several su ch room s. Cast room equ ipm en t an d su pplies certain ly vary accordin g to local cu stom s an d resou rces.

orth opedic or trau m a patien ts by applyin g di eren t kin ds o im m obilization or stabilization tech n iqu es. In th eory, a m odern cast room is a w ell-equ ipped w orkin g place. Wh ile in th e past, th e cast room w as u sed exclu sively or th e application o plaster o Paris casts, today, th e room is u sed or m an y di eren t types o treatm en t. O ten , several syn th etic m aterials are u sed in com bin ation . Th is requ ires a sa e an d clean w orkin g space or both th e tech n ician as w ell as th e patien t ( ig 5 ).

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ogistics and resources in the cast room

Th e cast room sh ou ld also be u sed to store relevan t equ ipm en t, m aterials, an d in stru m en ts. Th e equ ipm en t or closed redu ction o displaced ractu res or dislocation s, u n der sedation or region al an esth esia, sh ou ld also be m ade available.

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The ide al cast room

a Cast room with from le ft to right m obile im age inte nsi e r C arm , ce iling m ounte d traction e xte nsion s stem with mobile pulle , cast table, open storage room, shelve s or cupboards for storage and dail use , wor ing ban with plaste r basin and installe d plaste r trap se e n through ope ne d cupboard doors

Space for docum e ntation with PACS acce ss and de s c

Ce iling m ounte d e xamination lam p with e nough space to position the C arm

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Ce iling m ounte d e xte nsion s ste m and h gie ne corne r

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Ca s t ro o m fe a t u re s a n d fa cilit ie s

In an y m odern cast room , th e ollow in g eatu res an d acilities are recom m en ded an d u se u l: • Applian ces or ph ysiological m on itorin g du rin g procedu res • An esth esia acility • Mon itorin g equ ipm en t (NIBP m on itor, SpO 2 pu lse oxim eter, ECG) • Resu scitation equ ipm en t is also n ecessary, w ith oxygen , su ction , an d ven tilation aids, con sisten t w ith sa ety requ irem en ts or sedation an d/ or an esth esia • Nitrou s oxide delivery system or storage space or a portable n itrou s oxide delivery system overh ead service pan el • En ergy an d w ater su pply • Traction an d redu ction devices • X-ray f lm view er (tw o pan els are pre erable) or a digital im agin g system (pictu re arch ivin g com pu ter system ) station • Space or docu m en tation (con ven tion al w ritin g desk or com pu ter) • Plaster basin • Sin k an d drain w ith a plaster trap • Cast w ork ben ch • Storage or ban dages, an d plaster an d cast m aterials or daily u sage • Storage or oth er cast m aterials an d cru tch es easily accessible rom th e cast room .

ig 5 a Plaste r of Paris POP re sidue afte r dipping thre e slabs of POP splint longue tte The drain is not close d com ple te l , inste ad, a sim ple ove r ow s ste m is use d

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Th e space m u st be adequ ate, w ith an exam in ation cou ch or equ ivalen t, eg, a cast table th at can be accessed rom all sides. Th e room sh ou ld be at least 20 m 2 bu t pre erably closer to 35–40 m 2 in size, exclu din g storage areas or m aterials an d cru tch es. Th e cast room sh ou ld be large en ou gh to roll a bed in side (see ig 5 ). a lls a n d flo o r

All su r aces sh ou ld be w ash able. Th e edgin g strips betw een w alls, ceilin g, an d oors sh ou ld be cu rved in order to allow or better clean in g. Th e w alls sh ou ld be sh ielded in order to o er protection again st radiation —th is m ay be specif ed by n ation al regu lation s—an d pre erably be treated w ith sprayed plastic skin or su r aced w ith epoxy resin pain ts. Alth ou gh stain less steel su r aces are expen sive, th ey allow excellen t clean in g an d are du rable. Ceram ic tiles are o ten porou s an d, th ere ore, do n ot allow e ective clean in g. Th e oor su r ace sh ou ld h ave a n on slip coatin g.

ig 5 Cast be nch with wate r basin right and a m ovable plaste r trap be ne ath the basin

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

A sou rce o w ater is requ ired, pre erably clean tap w ater. Th e sin k sh ou ld h ave an over ow system in order to avoid in u n dation s ( ig 5 a ). A oor drain is option al. A plaster trap ( ig 5 ) is requ ired or discarded plaster application w ater as th e plaster residu e w ill block n orm al drain s. A separate w ash basin ( ig 5 c) is n ecessary, w ith h ot an d cold w ater, or h an d w ash in g be ore an d a ter patien t con tact as w ell as a ter applyin g a cast. Soap an d disin ectan t dispen sers as w ell as a paper tow el dispen ser are th u s requ ired. I pn eu m atic devices are to be u sed, com pressed air con n ectors are n ecessary. A m an agem en t system or u sed m aterials sh ou ld be establish ed, as som e m aterial residu es can be recycled, an d som e can be reu sed. Som e cast residu es (w aste) can be discarded w ith gen eral h ospital w aste. Nation al an d in tern ation al protocols or con tam in ated an d/ or poten tially in ectiou s m edical w aste disposal m u st be ollow ed.

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Ca s t ro o m lig t in g

Wh erever possible, access to n atu ral dayligh t is ideal in th e cast room rom clerestory (h igh -set) w in dow s, or access to ligh t via glass corridor pan els. Th e electric ligh tin g sh ou ld resem ble dayligh t w ith a color tem peratu re o approx. 5,500 Kelvin an d an illu m in ation correspon din g to n atu ral ligh t ( u ll spectru m ligh t). Ligh t bu lbs or h alogen bu lbs are u su ally in stalled. In m odern ligh tin g tech n ology, u orescen t tu bes em ittin g n atu ral ligh t sim ilar to dayligh t or u ll spectru m ligh t are u sed. Th e color tem peratu re correspon ds to, eg, Eu ropean n orm (EN) 12,464 w ith 5,300–6,500 Kelvin , an d th e lu m in aire n eeds a capacity o 5,000–10,000 lu x. In recen t years, LED lam ps h ave been in trodu ced in to ligh tin g con cepts in h ospitals an d cast room s. Th e n ation al gu idelin es o w orkplace ligh tin g sh ou ld be respected. 5

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Th e cast room sh ou ld h ave appropriate electrical con n ection s or an electric cast saw , an esth esia equ ipm en t, an d oth er m edical devices su ch as a ligh t box on w h ich to display th e relevan t x-rays.

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Su rgica l e a m in a t io n la m p s

In order to exam in e w ou n ds or skin problem s, good ligh t is n eeded. Th e exam in ation ligh t, eg, LEDs m ou n ted on w alls or th e ceilin g, can be ocu sed an d adju sted to illu m in ate th e area o in terest ( ig 5 3 ).

ig 5 3 Ce iling m ounte d e xam ination light with focusable light be am The im age also shows a se rvice unit with soc e ts for ox ge n, com pre sse d air, e le ctric suppl , e tc m ounte d on the wall

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ogistics and re source s in the cast room

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e n t ila t io n , a ir co n d it io n in g , a n d d u s t e t ra ct io n

Th e cast room is n ot an aseptic operation th eatre, h ow ever, adequ ate ven tilation is requ ired, pre erably air con dition in g. Wh en u sin g a cast saw , du st extraction via an extraction n ozzle f xed directly to th e oscillatin g cast saw blade is recom m en ded. Su rgical m asks sh ou ld be available in case o n eed.

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Tra ct io n e t e n s io n s s t e m

For th e application o m ore elaborate casts, an exten sion table (eg, Cotrel or Hess) or a ceilin g-m ou n ted traction system is n ecessary to position an d h old th e patien t or extrem ity in th e righ t position ( ig 5 4 ). Th ese system s are certain ly requ ired w h en pelvic POP casts or corsets or spin e ractu res are applied.

St o ra ge ro o m

A storage room is n ecessary or stockin g th e cast m aterials at room tem peratu re, observin g th e requ ired h u m idity levels, an d en su rin g secu rity. I possible, th e room sh ou ld be directly accessible rom th e cast room . o cu m e n t a t io n , a cce s s t o p a t ie n t re co rd s , ra vie in g s t a t io n

Th e cast room m u st o er space or docu m en tation an d view in g o x-rays. At th e very least, a con ven tion al x-ray view er (ligh t box) sh ou ld be available ( ig 5 5 ) as w ell as a desk or con sole or h an dw ritten m edical docu m en tation . In accordan ce w ith bu ildin g requ irem en ts, access to th e electron ic h ospital in orm ation system sh ou ld be in stalled, w h ich also m ean s access to th e pictu re arch ivin g com pu ter system (PACS) ( ig 5 6 ).

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ight box, analog x ra vie we r

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ig 5 4 Traction e xte nsion s ste m , e g, use d for suspe nde d nge r traps to re duce distal radius fracture s se e ig in chapte r racture s, dislocations, and subluxations of the uppe r e xtre mit , with ce iling rail with crab

pulling the chain the crab can be m ove d and positione d ove r the patie nt

ig 5 6 The PACS vie wing station with thre e m onitors, the le ft one for administration and m e dical docum e ntation, the othe r two for im age anal sis and com parison

andle to re le ase or tighte n the chain

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

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St o ra ge s p a ce fo r ca s t m a t e ria ls fo r d a il u s a ge

All m aterials an d in stru m en ts n eeded in daily plaster or syn th etic cast application sh ou ld be easily accessible. Th e storage sh ou ld be organ ized clearly an d appropriately ( ig 5 ).

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Pla s t e r a n d ca s t ca r t t ro lle

For th e cast trolley, it is pre erable th at a cart m ade o stain less steel is u sed, an d w h ich is both con ven ien tly located an d able to be m oved in to a com ortable w orkin g position . It also n eeds to be large en ou gh to h old th e requ ired m aterials. Som e trolleys accom m odate a bu cket or bow l or w ater ( ig 5 ). 3 3

o ile ca s t t a le

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Havin g access to an adequ ate cast table is im portan t w h ile applyin g a POP or syn th etic cast ( ig 5 , ig 5 ). It su pports th e patien t in th e requ ired position an d o ers en ou gh space or th e su rgeon or tech n ician to w ork in an appropriate m an n er. It sh ou ld also be radiolu cen t, tran sportable, an d easy to clean . I possible, th e table sh ou ld be adju stable in h eigh t.

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Th e ollow in g equ ipm en t w ith in th e cast room is u se u l an d accepted: • Storage space or ban dages, plaster, an d cast m aterials or daily u sage • Plaster an d cast cart (trolley) • Cast table • Mobile im age in ten sif er (C-arm ) system or con trolled ractu re redu ction • Materials or redu ction an d stabilization .

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b ig 5 E uippe d cast room at the nive rsit of Me dicine in t tinge n, e rman Mate rials for cast padding are store d above the cast wor ban , POP splint longue tte s on the le ft side of the cast wor be nch, and cushions for positioning e xtre m itie s are on the right

ig 5 a Plaste r and cast cart trolle for m obile use or in the cast room a A m obile cast basin is m ounte d on the le ft Ope n drawe rs show a full e uippe d cast trolle with cast and padding m ate rials re ad to use

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A m obile x-ray/ im agin g apparatu s or C-arm is recom m en ded or th e direct con trol o adequ ate redu ction o ractu res ( ig 5 ). Radiation sa ety m easu res are im perative, in clu din g sta train in g, protective sh ieldin g or patien t an d sta , an d periodic radiation ph ysics testin g. 3 5

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St o o l fo r s u rge o n o r ca s t t e c n icia n

A stool w ith adju stable h eigh t is also requ ired. Th is m akes it m ore com ortable w h ile w orkin g on th e patien t. In addition , it can be u sed w h en a lim b n eeds to h an g dow n o th e table, eg, du rin g application o a below -kn ee cast or a m alleolar ractu re. Th e su rgeon can sit on th e stool an d rest th e m etatarsal h eads on h is kn ee in order to keep th e an kle plan tigrade w h ile applyin g a m olded below -kn ee cast.

Cu s io n s a n d s u p p o r t fo r e t re m it ie s

Position in g m aterials sh ou ld also be available in proxim ity to th e cast table (see ig 5 ). Th igh su pports are u se u l or th e application o a lon g leg cast. Altern atively, a kn ee su pport is recom m en ded ( ig 5 . A low ootstool is a valu able aid or am bu latory patien ts tran s errin g to th e cast table. It also serves w ell as a low er seat, i su ch is requ ired, or th e cast tech n ician or su rgeon .

Image intensifier

Display screens

X-ray tube

ig 5 An im age inte nsi e r C arm in position ove r the patie nt, with a trolle with double scre e n displa ig 5 A m ovable cast table with h draulic he ight ad ustable sup port plate , upholste re d with foam cove re d b a washable fabric At the top e nd, one third of the support plate is se parate l ad ustable a pape r re se rvoir for single use cove rage of the support plate is xe d to the top e nd

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An ad ustable cast table

ig 5 A ne e re st, for supporting the ne e while appl ing a short le g cast, or for supporting the le g while appl ing a long le g cast The ne e re st should be high e nough to allow the ne e to be nd at about de gre e s, and the padding should be cove re d in plastic vin l she e t ing, which is e asil wipe d cle an afte r use

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Th ree m ajor grou ps o in stru m en ts are in u sage in th e cast room (see ig 5 3 an d Ta le 5 ): • POP cu ttin g sh ears an d saw s • Plaster spreaders • Scissors w ith a blu n t protection en d.

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A se le ction of cast instrum e nts An e le ctric oscillating cast saw, spre ade rs, scissors, and she ars

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An electric plaster saw is a w ired or w ireless oscillatin g saw or th e rem oval or w in dow in g o plaster or cast m aterial. Th e saw can be u sed w ith a variety o saw blades, depen din g on th e m aterial to be cu t or th e open in g to be m ade. Modern saw s are o ten com bin ed w ith a vacu u m clean er in order to avoid excessive du st. Electric cast cu tters requ ire blades to be replaced periodically. Spare blades an d an appropriate w ren ch are n ecessary. For tips on th e u se o a cast saw see ch apter 14.1 Overview o cast, splin t, orth osis, an d ban dage tech n iqu es.

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Be ore startin g th e application o a cast, th e su rgeon or cast tech n ician w ill prepare or th e cast procedu re. Th is in clu des m akin g su re th at all item s n eeded are at h an d becau se an y in terru ption on ce th e application o a cast h as been started cou ld resu lt in problem s. To in terru pt th e procedu re, even or a sh ort period, m ay resu lt in a POP cast th at is delam in ated (layered or pu -pastry) an d w h ich , th ere ore, w ill be w eaken ed. Th u s, correct preparation is essen tial. In addition to th e cast m aterials, paddin g, as w ell as th e in stru m en ts n eeded or cu ttin g or trim m in g th e cast, sh ou ld be readied.

Cu ttin g sh ears are u sed to split or rem ove a cast. An electric cast saw can be u sed in stead. A cast kn i e or m an u al sh ears w ill on ly w ork to split w et POP casts. A ter splittin g th e cast, a spreader w ill h elp to w iden th e gap to allow th e scissors to be in trodu ced an d to cu t th e paddin g an d tu be ban dage (stockin ette) com pletely.

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ogistics and re source s in the cast room

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Name lectric oscillating saw

unction For cutting the cast

Things to keep in mind lectricity needed oisy Frightening especially for children

To control the angle of the extremity

Take care to ensure precise positioning

Lister bandage scissors

For cutting padding and undercast materials and to cut semirigid (soft) casts

nsure the blunt side of the scissors glide over the skin

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runs scissors

specially for P P

Take caution with patients with skin problems

nsure the blunt side of the scissors glide over the skin Take caution with patients with skin problems

Universal scissors

For standard bandages

ot appropriate for thick material ecomes dull or blunt easily

Stille plaster shears

To remove P P or synthetic casts

Some strength needed Dif culties in case of thick casts Dif culties with sharp angles

Plaster cast spreader

Cast bender

To spread or widen a bivalved plaster cast

nsure good positioning Take care not to cut or scratch the skin

To widen the cast at the borders

Take care not to cut or scratch the skin

To remove the P P casts of children

Plaster saw

To handsaw P P casts

Good when electricity is not available Less frightening ore time consuming

Plaster knife

To trim or cut (wet) P P casts

The knife should be sharp Care should be taken not to wound the patient Techni ue: cut from bottom up and not from top down

Ta le 5

Se le ction of instrum e nts ne e de d for the application or re m oval of POP or s nthe tic casts

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

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Each cou n try h as its ow n regu lation s in regard to w h o is allow ed to apply an d rem ove casts. Th e poten tial or h arm is great, particu larly in developin g cou n tries w h ere patien ts m ay n ot be able to get h elp i com plication s arise. On ly train ed an d licen sed people sh ou ld apply casts, an d, w h ile in orm ally train ed assistan ts can be h elp u l, th ey m u st be su pervised an d n ot le t to apply or rem ove casts on th eir own .

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• Typically situ ated in close proxim ity to th e em ergen cy or operatin g departm en ts, th e cast room is a clean area dedicated to th e application o casts, su pport ban dages, an d oth er n on em ergen cy treatm en ts • Th e cast room sh ou ld h ave adequ ate size, storage, pow er su pply, ligh tin g, an d ven tilation • Th e cast room sh ou ld h ave th e relevan t equ ipm en t or daily application o casts an d splin ts, in clu din g dedicated tables, ligh t boxes or PACS or view in g x-rays, an d a u lly stocked cast trolley, as w ell as all relevan t scissors, spreaders, an d oth er cu ttin g in stru m en ts • An ideal situ ation is th e em ploym en t o a dedicated cast tech n ician to m ain tain th e cast room an d to provide skilled param edic assistan ce.

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It is very im portan t to u se all in stru m en ts an d devices in th e appropriate m an n er. Main ten an ce w ith adequ ate clean in g, lu brication , an d sh arpen in g o tools w ill in crease th e li etim e o in stru m en ts an d redu ce costs. Som ebody sh ou ld take respon sibility or th e cast room . Th e tasks in clu de clean in g an d restockin g in ven tory as w ell as th e m ain ten an ce an d en su rin g th e secu rity o th e equ ipm en t.

Th e cast tech n ician is a train ed m edical em ployee assistin g or w orkin g u n der th e su pervision o a su rgeon . Th e th eoretical an d practical train in g is ocu sed on th e an atom ical an d u n ction al aspects o th e m u scu loskeletal system . Th ese param edics h ave th e requ ired kn ow h ow to deal w ith a variety o trau m a or orth opedic related problem s. Th ey are am iliar w ith th e properties an d application tech n iqu es o th e di eren t m aterials an d are expert in preparin g POP an d syn th etic splin ts an d casts, braces, an d oth er m edical application s. Th ese tech n ician s are also respon sible or trim m in g an d rem ovin g th e di eren t types o casts an d an y traction (exten sion ) system s. 4

s s is t a n ce d u rin g ca s t in g

Man y casts can be applied m ore e ectively w ith th e h elp o a w ell-train ed assistan t. Th is assistan t m ay be requ ired to su pport a lim b in a correct position , dip POP rolls in to w ater, or even apply th e plaster w h ile th e su rgeon h olds th e lim b in place. Adequ ate su pport or a ractu red lim b du rin g castin g redu ces pain an d allow s a better cast to be applied.

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

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Pla s t e r o f Pa ris Discove r and te rm plaste r of Paris Prope rtie s Che m ical and ph sical fe ature s ualitie s and t pe s Application characte ristics Te m pe rature se nsitivit and he at form ation or ing tim e e m oval of plaste r of Paris casts Possible proble m s disadvantage s

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S n t e t ic ca s t m a t e ria ls Prope rtie s ualitie s and t pe s Te m pe rature se nsitivit and he at form ation or ing tim e e m oval of s nthe tic casts

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Pla s t e r o f Pa ris ve rs u s s n t e t ic ca s t m a t e ria ls brid casts Cast re m oval e ight of casts iom e chanics e com m e ndations Se m irigid casts Se m irigid casts for acute in urie s—prim ar de finitive care

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n d e rca s t m a t e ria ls Tube bandage s Cast padding

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

Pro p e r t ie s

Pla s t e r o f Pa ris

Plaster o Paris as u sed in casts or splin ts or ractu re patien ts h arden s du e to a sim ple ch em ical reaction . How ever, it is possible to vary th e eatu res o th e process (settin g speed, stren gth , etc) accordin g to di eren t requ irem en ts.

is co ve r a n d t e rm p la s t e r o f Pa ris

Th e earliest arch eological eviden ce in dicatin g th e u se o gypsu m plaster dates back m ore th an 9,000 years, w ith discoveries in Syria an d An atolia, Tu rkey. Abou t 5,000 years ago, Egyptian s began to produ ce a pow der by h eatin g gypsu m in open -air res. Wh en m ixed w ith w ater, th is pow der, a less h ydrated orm o gypsu m , becam e a paste th at h arden ed as it dried. Th e an cien t Egyptian s u sed th is paste as grou t in order to join ston e blocks, like th ose o th e Great Pyram id o Ch eops. Th e Egyptian s also applied plaster to th e in terior w alls o th e palaces an d tom bs o th eir ph araoh s [1]. Pow dered (deh ydrated) gypsu m cam e to be called “plaster o Paris” becau se th e m aterial w as abu n dan t an d th ere ore w idely u sed or bu ildin g pu rposes by Parisian s. In th e 17th cen tu ry, Paris h ad becom e th e “capital o gypsu m ”, an d th e Kin g o Fran ce ordered th at th e w ooden bu ildin gs o Paris be covered w ith plaster in order to protect th em again st spreadin g res [1]. In itially, plaster o Paris (POP) w as u sed by th e con stru ction in du stry, an d w as later adopted or treatin g u n stable in ju ries, an d or m an u actu rin g. How ever, it w as th e Du tch arm y su rgeon An ton iu s Math ijsen th at w as speci cally given

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s ica l fe a t u re s

Gypsu m is a so t sedim en tary crystallin e rock, plen ti u l w h ere large bodies o w ater disappeared by evaporation in earlier geological eras. Ch em ically, it is calciu m su l ate dih ydrate (CaSO 4 ·2H2 O). Wh en h eated at an appropriate tem peratu re, gypsu m gives o som e o its w ater in th e orm o steam an d tu rn s in to th e dry w h ite pow der m en tion ed above (calciu m su l ate h em ih ydrate), ie, POP. Th e reaction equ ation is CaSO 4 ·2H2 O + h eat –› CaSO 4 ·½ H2 O + 1½H2 O. Th is process is called calcin ation . It occu rs a ter n atu rally occu rrin g gypsu m h as been cru sh ed, su r ace-dried, an d grou n d. Wh en th e h em ih ydrate pow der is su bsequ en tly m ixed w ith w ater, an exoth erm ic h ydration reaction sets in leadin g back to th e dih ydrate state, ie, solid gypsu m . Wh ile th is reaction occu rs, th e m aterial orm s a paste, w h ich expan ds sligh tly (abou t 1% ) du rin g settin g [1]. With in m in u tes, th e paste sets in to a solid m ass com prised o in terlaced gypsu m crystals, CaSO 4 ·2H2 O. Additives can be u sed to vary th e settin g tim e. Wh en potassiu m su l ate is u tilized as an accelerator, or sodiu m borate as a retarder, th e e ect is a qu icker or slow er settin g o th e m aterial.

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Plaster casts h ave been th e stan dard rigid ban dagin g or posttrau m atic or postoperative im m obilization in trau m a su rgery an d orth opedics or at least 150 years. How ever, over recen t decades, syn th etic altern atives w ith sim ilar an d/ or variou s di erin g properties h ave becom e in creasin gly available. Th e qu estion or th e ph ysician is w h ich m aterial to u se given a particu lar situ ation . Th is ch apter th ere ore takes a closer look at th e im portan t properties, ben e ts, an d disadvan tages o each o th e key cast m aterials.

credit or developin g plaster ban dages, du rin g th e Crim ean War (1853–1856), as h e developed a process or applyin g cotton ban dages lled w ith dry, pow dered POP, th en w ettin g th e ban dages on ce th e lim b w as appropriately position ed. He n oted th at as th e ban dages dried, th ey h arden ed, an d su rgeon s cou ld th en sh ape th em by h an d w h ile th e plaster set. Th e ease an d con ven ien ce o u sin g th ese ban dages led to th eir w idespread adoption in pre eren ce to earlier types o splin ts [2] (see ch apter 2 History o castin g— rom th e begin n in g to th e presen t day).

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Properties of cast materials

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Plaster is applied to a specially prepared abric carrier th at m in im izes plaster loss rom th e dry abric, an d redu ces its du stin ess ( ig 6 ). Plaster o Paris ban dages n orm ally con sist o a carrier abric (cotton gau ze or w oven len o cloth ) sprayed w ith h em ih ydrate plaster. Th e ban dage is u su ally rolled on a rou n d core or better h an dlin g an d stability du rin g th e application process ( ig 6 ). Several roll w idth s are available to accom m odate di eren t body parts an d sizes o patien ts. Be ore th ey are w et, plaster rolls can be cu t in to n arrow er w idth s w ith a sh arp kn i e.

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In addition to rolls, POP is also available as splin ts (also variou sly kn own as slabs or lon gu ettes) w h ich are in dividu al strips o plaster-coated abric o several di eren t dim en sion s an d package sizes ( ig 6 3 ). For con ven ien ce, splin ts (lon gu ettes) are o ten packaged in olded grou ps o m u ltiple layers. Slabs o splin t (lon gu ette) can also be orm ed rom POP rolls, w h en th ey are u n rolled to create a strip o th e

desired w idth , len gth , an d n u m ber o layers. In som e produ cts, a zigzag-cu t edge preven ts rayin g as w ell as crackin g o th e edges. Moistu re resistan t packagin g protects th e plaster ban dages rom u n desired h arden in g in h u m id en viron m en ts or du rin g prolon ged storage. Additives added du rin g th e abrication o plaster- abric com posites can be u sed to in f u en ce th e properties o th e plaster, eg, th e tim e it takes th e plaster to set (h arden ) [3]. Sin ce th ere are m an y varieties o plaster available w orldw ide, it is im portan t th at all u sers m ake th em selves am iliar w ith th e produ cts available in th eir h ospital or clin ic, particu larly in regard to settin g tim e an d proper in itial w etn ess. Th e settin g tim e is approxim ately 10–12 m in u tes w h en 20° C dippin g w ater is u sed, an d varies n ot on ly w ith th e type o plaster bu t also w ith variation s in w ater tem peratu re. A ter m oisten in g, m ost POP o ers good to excellen t con orm ability an d m odelin g properties. Som e preparation s are very cream y, som e are very du rable. Th e plaster is easily m olded, so it con orm s closely to th e body part to w h ich it is bein g applied [4]. Sh apin g th e plaster du rin g settin g is a tech n iqu e th at can be u sed in order to cou n teract de orm in g orces, to correct m obile de orm ity su ch as a pliable clu boot, or a h ealin g ractu re be ore it com pletes con solidation , or to im prove con tain m en t t in order to stabilize an u n stable ractu re in to an atom ical align m en t. Appropriate paddin g m u st be placed betw een th e skin an d an y im m obilizin g m aterial. Th e im portan ce o paddin g, an essen tial part o cast application , is discu ssed in m ore detail in th is ch apter in topic 5 Un dercast m aterials.

ig 6 Plaste r of Paris is xe d on a spe ciall pre pare d fabric carrie r in orde r to m inim i e plaste r loss during the dipping proce ss and application

ig 6

A POP roll, rolle d onto a round core

ig 6 3 A POP splint longue tte com prise d of se ve ral fabric la e rs im pre gnate d with POP

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

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Po ro s it a n d a s o rp t io n

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Th e n al stren gth o th e plaster cast m aterial depen ds on its crystal stru ctu re. I th e cast is m an ipu lated w h ile it is begin n in g to h arden , or preven ted rom dryin g ou t, it w ill be w eak becau se o im paired crystallization . Dryin g is delayed in cold or m oist con dition s an d accelerated in a w arm an d dry en viron m en t. Th e cast stren gth also depen ds on th e layers o plaster (th ickn ess) an d th e sh ape o th e cast con tou red arou n d th e in ju red extrem ity. As m en tion ed, excessive plaster in creases w eigh t, bu lk, an d h eat produ ction . Bu t on th e oth er h an d, com plian ce o th e trau m a patien t is also m an datory ( ig 6 5 ). It is im portan t th at a plaster cast does n ot becom e w et a ter dryin g, as th e POP w ill literally dissolve.

Th e porosity o plaster casts allow s tran sm ission o perspiration , w h ich perm its skin m oistu re to dry. How ever, plaster also absorbs liqu ids readily, as seen w ith w ou n d drain age ( ig 6 4 ), or w h en th e ou tside o a cast becom es w et. Absorb-

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b ig 6 4 a Demonstration of moisture absorbance b a plaster cast a POP e asil absorbs wound drainage and othe r li uids Inne r aspe ct of the POP cast The he m atoma has soa e d the padding and POP cast

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a n d s t a ilit

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Th e ability to loosen a circu m eren tial cast is essen tial in order to relieve gen eralized tissu e pressu re, w h ich occu rs w h en a lim b sw ells in side a n on com plian t cast. Th is in creasin g pressu re can cau se com partm en t syn drom e th at resu lts rapidly in poten tially perm an en t loss o m u scle an d n erve u n ction . Casts m ay also n eed to be altered to relieve ocal pressu re th at m igh t lead to a pressu re sore or n erve in ju ry. [5] So, it is desirable th at th e plaster is su cien tly pliable an d plastically de orm able in order to allow a circu m eren tial cast to be spread apart alon g a sin gle lon gitu din al cu t, an d th u s loosen ed (o ten called “u n ivalvin g”, as opposed to “bivalvin g” w ith tw o cu ts, w h ich m akes th e cast rem ovable bu t m ore u n stable). Plaster o Paris is w ell-su ited or th is u n ivalvin g tech n iqu e, sin ce a lon gitu din al saw cu t can u su ally be spread en ou gh to ach ieve th e desired loosen in g.

in g m oistu re w eaken s th e plaster. On ce th e plaster cast becom es soaked, it so ten s an d loses its rigidity. I th is h appen s w h ile it is still n eeded, th e cast m u st be replaced.

b ig 6 5 a A POP cast can bre a if a not e nough la e rs are applie d, or the re is a con ict be twe e n the stabilit of the cast and the com pliance of the patie nt

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p p lica t io n c a ra ct e ris t ics Co n fo rm a ilit a n d p la s t icit

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Klaus Dre sing, os Engele n

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It is th u s im portan t to add stren gth by proper castin g tech n iqu es. For exam ple, th e m olded lon gitu din al rein orcem en t ridges on th e su r ace o a plaster cast or splin t can dou ble stren gth an d sti n ess w ith on ly a 20% in crease in w eigh t [6]. Th e caregiver m u st balan ce th ese actors in order to create a cast o optim al stren gth an d w eigh t, w ith m in im al risk o th erm al in ju ry. Becau se it con orm s so w ell to th e u n derlyin g body con tou rs, a properly m olded POP cast or splin t produ ces less riction (sh ear orces) on th e skin su r ace th an oth er cast m aterials. Th is provides an optim al en viron m en t or h ealin g o w ou n ds, in clu din g skin gra ts [3].

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Prope rtie s of cast mate rials

Proper h an dlin g o th e plaster is im portan t an d th is starts w ith th e dippin g process. Th e w ater depth sh ou ld be at least 20–30 cm , so th at an y roll u sed can be su bm erged vertically below th e w ater su r ace. Th e colu m n o w ater h elps to press ou t th e rem ain in g air betw een th e layers o plaster. Th e ban dages rapidly becom e w et w h en placed in to w ater in th e correct m an n er ( ig 6 6 ). Th e im m ersion tim e is ap-

proxim ately th ree secon ds, or u n til air bu bbles stop appearin g, w h ich in dicates th at th e plaster is soaked com pletely. Th e plaster m u st be u n i orm ly w et. Dry spots decrease th e qu ality an d stren gth o th e plaster. Dry layers cau se delam in ation , produ cin g so-called “pu pastry plaster” ( ig 6 ). A ter dippin g, th e plaster roll or splin t (lon gu ette) m u st be squ eezed ju st en ou gh to rem ove excess w ater, an d to distribu te th e rem ain in g w ater u n i orm ly. Th e latter is ach ieved by h oldin g each en d o th e plaster roll w h ile gen tly w rin gin g or squ eezin g it as it is rem oved rom th e w ater a ter bein g soaked th rou gh . Su cien t w ater m u st rem ain in order to create a th ick f u id plaster paste. Th e layers o plaster are sm ooth ed togeth er by m an u al lon gitu din al com pression m otion s; th e resu lt is a h om ogen ou s cast or splin t ( ig 6 ).

a ig 6 6 If dippe d corre ctl into e scape from the POP la e rs

cm wate r de pth, air bubble s

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ig 6 Puff pastr plaste r re sulting from an insuf cie nt dipping proce ss and de lam ination of the POP la e rs

ig 6 a Optim all pre pare d POP splint longue tte It is a hom oge nous slab as the re sult of rubbing the m oist paste of plaste r into the fabric a ie w from above Slab cut vie w from the side All la e rs form a hom oge nous com posite

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Rem em ber, a POP cast is n ot w ater resistan t.

o r in g t im e

Th e stren gth o a POP cast m easu res betw een 5 an d 10 m egapascals o pressu re (MPa), w ith a ben din g m odu lu s o 2–3 gigapascals (GPa) [7]. Becau se o th is relative sti n ess, circu m eren tial POP casts, applied to resh in ju ries or postoperatively, sh ou ld be split an d spread apart at least alon g on e side in order to accom m odate sw ellin g an d to avoid excessive in crease o in terstitial f u id pressu re. For th e orearm , a dorsal split is m ore stable th an oth ers, an d allow s th e cast to retain th e redu ction better [8]. Plaster o Paris is w eaker in ten sion , bu t stron ger in com pression [9]. With low -ten sile stren gth an d n orm al loadin g, th e m aterial loses its rigidity over tim e [9]. Addin g on e or m ore lon gitu din al ridges to a POP cast or splin t in creases its stren gth an d lon gevity [6].

Th e plaster can on ly be w orked or a period o 3–5 m in u tes, depen din g on w ater tem peratu re an d plaster bran d. Th e in itial settin g tim e takes 10–12 m in u tes. Th e requ ired tim e or com plete settin g, an d i allow ed rst perm issibility or w eigh t bearin g, is 24–48 h ou rs depen din g on th e th ickn ess o th e cast. e m o va l o f p la s t e r o f Pa ris ca s t s

For rem oval an d splittin g o POP casts, cast saw s are u su ally u sed. A ter com plete h arden in g, POP casts are so h ard an d sti th at n orm al scissors or kn ives are u seless. Special plaster scissors eg, Stille, can be u sed to open or rem ove th e cast (see topic 3 in ch apter 5 Logistics an d resou rces in th e cast room ). Po s s i le p ro le m s d is a d va n t a ge s

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Te m p e ra t u re s e n s it ivit a n d

e a t fo rm a t io n

I a plaster ban dage is im m ersed in cold w ater (< 15° C) th e in itial settin g w ill be delayed an d th u s th e w orkin g tim e len gth en ed. Con versely, i very rapid settin g is requ ired, soakin g th e ban dage in w arm w ater (> 25° C) accelerates th e rate o reaction . How ever, w ater tem peratu res above 50° C w ill slow dow n settin g an d at 100° C n o settin g w ill occu r at all. Th e exoth erm ic reaction du rin g th e h arden in g o POP m ay cau se sign i can t th erm al bu rn s [5, 10–13], especially i th e dip w ater tem peratu re is h igh . Usin g a n orm al w ater tem peratu re o (18–20° C) is essen tial. Key elem en ts th at can cau se bu rn in ju ries in clu de cast th ickn ess, dippin g w ater tem peratu re, an d th e u se o pillow s, especially w ith plastic covers, w h ich preven ts h eat dissipation [12, 14, 15].

Poten tial disadvan tages o plaster in clu de th e tim e requ ired or h arden in g, th e relatively h eavier w eigh t com pared to ligh ter syn th etic m aterials, th e act a POP cast can break easily an d is a ected by w ater an d m oistu re, an d th e am ou n t o h eat th at can be produ ced, particu larly w ith w arm dippin g w ater an d a th ick plaster cast [16–20].

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Th e key actors th at a ect plaster cast application in clu de: • Water tem peratu re u sed or dippin g th e plaster m aterial • Warm er w ater w ill accelerate settin g tim e • Colder w ater w ill slow dow n settin g tim e • Tepid w ater is recom m en ded or plaster dippin g • Air tem peratu re an d h u m idity • Plaster casts dry m ore rapidly w h en th e cast is exposed to circu latin g, dry air.

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Becau se o th e low stren gth -to-w eigh t ratio o POP, th icker casts are o ten u sed. How ever, th is produ ces m ore h eat an d in creases th e risk o bu rn in ju ries [5, 11].

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Du rin g application , it is im portan t to ru b th e m oist paste in to th e abric in order to obtain a sm ooth , u n i orm com posite in w h ich th e abric th reads are em bedded (like rein orcin g m etal bars in stru ctu ral con crete). Splin ts (lon gu ettes) 4–12 layers th ick sh ou ld sim ilarly be squ eezed an d ru bbed to spread th e plaster paste th rou gh th e abric be ore th ey are applied as rein orcem en t to a cast or as slab splin ts, h eld on to th e su r ace o an extrem ity w ith a abric roller ban dage. Splin ts (lon gu ettes) sh ou ld be ru bbed lon gitu din ally, typically on a w aterproo table top, so th ey adh ere to each oth er an d becom e a sin gle com posite. Several layers o paddin g can be added to th e su r ace o a settin g splin t be ore it is placed on th e patien t. Usin g a circu lar application o POP, th e layers o plaster sh ou ld be m olded sim ilarly, a ter th e w rappin g. Ru bbin g th e plaster w h ile it is w et, du rin g th e early ph ase o settin g, distribu tes th e plaster u n i orm ly th rou gh all abric layers in order to produ ce a sin gle com posite th at w ill n ot delam in ate.

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Klaus Dre sing, os Engele n

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S n t e t ic ca s t m a t e ria ls

Syn th etic cast m aterials typically con sist o on e layer o polyester kn it, berglass abric, polypropylen e kn it, or berglass ree polym er (th e latter also called th erm oplastic). Th e im portan t part o th e m aterial is th e kn itted abric im pregn ated w ith a polyu reth an e resin , th e prepolym er. Th e resin polym erizes an d h arden s a ter bein g exposed to h u m idity or w ater. As w ith plaster, u n i orm w ettin g is im portan t, in th is case, in order to ach ieve u n i orm polym erization . Gloves sh ou ld be u sed du rin g application becau se th e resin adh eres to skin an d cau ses irritation .

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Prope rtie s of cast mate rials

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Pro p e r t ie s

Syn th etic casts are o ten perceived as bein g m ore di cu lt to apply, an d th eir m oldability is less th an plaster. However, th ey retain th eir stren gth even wh en wet [16] an d th ey are ligh ter an d in ter ere less with x-rays [19, 21, 22]. Syn th etic casts h arden rapidly, an d soon ach ieve th eir n al stren gth ( ig 6 ). Modi cation s in th e orm u la o th e resin u sed can resu lt in eith er a rigid (h ard) or a sem irigid (so t) cast. Wh ile ligh t an d du rable, th e h ard cast tech n iqu e n everth eless h as som e disadvan tages. Th e m aterials are very rigid w ith h ard an d sh arp edges an d th ere ore an oscillatin g saw is u su ally n eeded or splittin g an d adju stm en t.

in ju red lim b to accelerate ractu re h ealin g [28]. Wh ile th is perh aps is easier to ach ieve by a ligh t, sem irigid so t cast, th is m ay also be accom plish ed by rigid casts. More im portan t th an th e type o cast m aterial is th at th e cast provides good su pport in a u n ction al position an d th at th e patien t is appropriately tau gh t an d train ed in u n ction al u se an d exercises. 3 3

u a lit ie s a n d t p e s Po l e s t e r

Syn th etic cast m aterial w ith a polyester abric carrier is coated w ith polyu reth an e resin . Stability an d f exibility o th e cast can be adju sted in dividu ally by th e n u m ber o layers applied. Few er layers o er h igh er f exibility w h ile m ore layers in crease stability in order to provide in creased im m obilization i an d w h ere n ecessary. Th e cast is m olded care u lly to t body con tou rs. Depen din g on th e n u m ber o layers u sed, cast scissors can be u sed to open th e cast an d adju st its size. Polyester castin g m aterial in ter eres less w ith x-ray im agin g th an plaster does. Th e cast edges stay so t an d f exible i th e m aterial is applied th in ly n ear th e edge. Th ese casts can be u sed eith er as an in itial or a su bsequ en t application . Patien ts are o ten m ore com ortable an d m ay be m ore com plian t du rin g reh abilitation . Yet an oth er advan tage is th at th is m aterial produ ces less du st du rin g cast rem oval.

Sem irigid (so t) casts provide sign i can t stability by m ean s o con tain m en t, com parable to a h ydrau lic cylin der. Th eir stability is o ten su cien t or m ain tain in g align m en t du rin g u n ction al u se o th e extrem ity, even in clu din g weigh t bearin g. Sarm ien to an d oth ers poin ted ou t th eir ben e ts or early u n ction al u se both in ractu res o th e u pper an d lower extrem ities, an d also dem on strated th e e ectiven ess o su ch casts an d braces or providin g th e n ecessary su pport [23–26].

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Th e f exible, sem irigid cylin der can adapt to th e ch an gin g orm o th e m u scu latu re, leadin g to con trolled com pression an d im proved circu lation [27]. Du e to th e h ydrostatic prin ciple o a sem irigid tu be, it is possible or th e u n ction al u se o th e

Sem irigid berglass m aterial is easier to apply an d to m old. Its settin g tim e is approxim ately ve m in u tes. Th e cast is ready or w eigh t bearin g a ter approxim ately 30 m in u tes. A ter h arden in g, so t casts are f exible, bu t lack elasticity. Sem irigid casts are easy to reapply, to clean , an d are ideal or treatin g trau m a an d in postoperative application s.

i e rgla s s rigid a n d s e m irigid ca s t s

Fiberglass abric w ith w ater-activated polyu reth an e resin n orm ally provides rigid, du rable im m obilization a ter a sh ort settin g tim e. Varyin g th e am ou n t or com position o resin can resu lt in di eren t levels o rigidity. Harden in g can be activated by air h u m idity alon e, bu t is m ore rapid a ter bein g dipped in w ater. Th e berglass m aterial h arden s qu ickly an d can bear w eigh t sh ortly a ter application [27].

Gloves sh ou ld be w orn du rin g application in order to protect th e caregiver’s skin rom th e polyu reth an e resin . Bu t th e edges o th e n ish ed sem irigid cast are sm ooth an d less abrasive th an a rigid cast, w h ich in creases th e patien t’s com ort. Th e layers con solidate w ell, o erin g im proved stren gth w ith ou t delam in ation .

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A s nthe tic long arm cast using se m irigid casting tape

Rem oval an d adju stm en t o sem irigid or so t casts can be don e w ith cast scissors alon e; th ere is n o n eed or a saw .

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

How ever, rigid berglass casts requ ire an oscillatin g cast saw or rem oval. 3 T e rm o p la s t ic

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4 Sp e cia l s n t e t ic m a t e ria ls a n d m a t e ria l co m in a t io n s Com bicast applications

In th e so-called “com bicast” tech n iqu e, rigid (h ard cast) splin t is in tegrated betw een tw o layers o sem irigid (so t cast) m aterial. Th is tech n iqu e, also called “san dw ich -tech n iqu e”, perm its th e con n ection o rigid splin t w ith circu lar w raps o sem irigid m aterial, m akin g th e en tire con stru ction stable [27, 29]. Su ch im m obilization can be applied by m oldin g it u sin g th e th ree-poin t xation tech n iqu e as described by Ch arn ley [30] (see topic 10 in ch apter 3 Prin ciples o castin g). Providin g f exibility in som e portion s o th e com bicast m ay perm it m ore m u scle u n ction th an is possible w ith a com pletely rigid cylin drical cast [27, 29]. Padde d s nthe tic casting m ate rial

Th ese prepadded splin ts can be applied directly to th e patien t’s skin an d secu red w ith a abric roller ban dage. Th e rigid cast m aterial kn it is im pregn ated w ith polyu reth an e resin in order to orm th e m oldable core o th e splin t. Mu ltiple layers o a kn itted berglass (or occasion ally polyester) abric are in tegrated between tw o layers o paddin g elt (eg, 100% polypropylen e) on th e side o skin con tact or a lm / paddin g cover on th e ou ter side. Th e ou ter side is typically covered w ith a n on w oven , w ater-perm eable abric. Wh en w et, th is m oisten s th e en tire splin t, en su rin g rapid an d u n i orm activation o th e resin . Th e m aterial can be h an dled w ith ou t u sin g gloves. Its settin g tim e is approxim ately 3–5 m in u tes an d th e splin t can w ith stan d sign i can t orces a ter approxim ately 20 m in u tes. Su ch castin g m aterial is available in several w idth s, in a th in , f atten ed m oistu re-proo alu m in u m oil tu be. It is available in precu t sizes as w ell as in a roll o several m eters len gth . Th e desired len gth (w ith its w rapper)

Pre cut unpadde d fibe rglass splints

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Syn th etic castin g m aterials produ ce less h eat du rin g polym erization th an is produ ced du rin g th e settin g o POP casts. Addition ally, becau se o th eir greater stren gth , less m aterial is n eeded or a cast.

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Th is variety o syn th etic cast ban dages con sists o a f exible, kn itted polyester abric w ith a th erm oplastic polyester coatin g. No resin is u sed. Th erm oplastic cast m aterial can be applied an d m olded w ith ou t gloves. With th erm oplastic m oldable castin g m aterial, w h ich is reversibly m oldable, th e sel -adh esive ch aracteristic is ach ieved by h eatin g in a h ot w ater bath or a steam h eater. Th e th erm oplastic polym er cast m aterial starts to be m oldable at or above th e respective so ten in g tem peratu re. Th e m aterial h arden s again u pon coolin g. Th e m aterial is w ater-resistan t an d perm eable to air an d w ater vapor. Its settin g tim e is approxim ately ve m in u tes; th e cast is ready or w eigh t bearin g a ter approxim ately 20 m in u tes. Rem oval is possible w ith ban dage or cast scissors.

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is cu t o w ith scissors. Th e cu t en d o th e oil w rapper on th e rest o th e roll m u st th en be clam ped closed in order to avoid air m oistu re cau sin g th e rem ain in g m aterial to h arden .

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Authors

Th e key actors th at a ect syn th etic cast application in clu de: • Tem peratu re o w ater u sed or dippin g th e syn th etic castin g m aterial • Warm er w ater accelerates settin g tim e • Colder w ater slow s settin g tim e • Tepid w ater is recom m en ded or syn th etic m aterials. 3 4

o r in g t im e

Th ere are tw o di eren t w ays to apply syn th etic cast m aterial. Norm ally th e m aterial is dipped in to tepid w ater (arou n d 18–20° C) an d th en applied to th e lim b. Th e w orkin g tim e u sin g th is tech n iqu e is abou t 2–4 m in u tes an d th e in itial settin g tim e takes abou t 6–8 m in u tes. An oth er w ay o applyin g syn th etic cast m aterial is th e dry application m eth od w h ere th e m aterial is rst applied to th e lim b an d th en m oisten ed by sprayin g w ater on it or by w rappin g it w ith a w et ban dage. Th is tech n iqu e gives th e cast tech n ician m ore w orkin g tim e an d is advised or di cu lt application s. Th e w orkin g tim e u sin g th is tech n iqu e is abou t 5–7 m in u tes an d th e in itial settin g tim e is 8–10 m in u tes. Th e com plete settin g tim e an d, i perm itted, w eigh t bearin g is approxim ately 30 m in u tes in both application tech n iqu es. 3 5

e m o va l o f s n t e t ic ca s t s

Sem irigid castin g m aterial is sim ply rem oved w ith cast scissors. How ever, a cast saw is requ ired or rigid syn th etic casts. Usin g syn th etic cast m aterials ( berglass, polyester, an d polypropylen e) h as advan tages an d disadvan tages. Users m u st becom e am iliar w ith th e properties an d optim al application tech n iqu es o th e m aterials available in th eir practice.

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Pla s t e r o f Pa ris ve rs u s s n t e t ic ca s t m a t e ria ls

Syn th etic m aterials, w h ich are kn ow n to be ligh ter, stron ger, an d less pron e to em it o en sive odors, are o ten pre erred by patien ts, especially or low er extrem ity im m obilization [31]. Bu t th ere are a w ide ran ge o actors to be con sidered w h en com parin g POP versu s syn th etic m aterials. In brie , th ese in clu de: • Greater m aterial costs o syn th etic • Sh orter w orkin g tim e or th e application o syn th etic • Less requ en t n eed or recastin g w ith syn th etic • Less abrasive an d sm ooth er edges in sem irigid syn th etic castin g • Heavier w eigh t o POP • Tim e requ ired or com plete settin g w ith POP • Th e am ou n t o h eat th at can be produ ced in POP, particu larly w ith w arm dippin g w ater or a th ick plaster cast. 4

rid ca s t s

It is possible to create a best o both worlds h ybrid cast by begin n in g w ith a th in n er layer o POP in order to take advan tage o its easy application an d excellen t m oldin g properties. On ce th is layer is su cien tly set, it is rein orced with an ou ter layer o rigid syn th etic m aterial or extra stren gth an d du rability bu t less w eigh t th an i on ly plaster w as u sed. Lim itin g th e am ou n t o syn th etic cast m aterial m ay be m ore cost e ective as well. An oscillatin g saw is requ ired or rem oval o su ch casts, especially or th e ou ter layer o syn th etic. 4

Ca s t re m o va l

A m ajor advan tage o sem irigid casts is th at th ey can be split, adju sted, or rem oved w ith cast scissors in stead o a cast saw . Particu larly w h en treatin g ch ildren , th e u se o oscillatin g saw s to split, cu t, or rem ove th e plaster or h ard cast ban dage con stitu tes a m ajor problem . A recen t case report ascribed death o a you n g ch ild w ith cardiom yopath y to an xiety associated with th e u se o an electric cast saw [32]. Th e au th ors also n oted tach ycardia du rin g cast rem oval in oth er patien ts an d its am elioration w h en h earin g protection w as provided, particu larly or patien ts you n ger th an 13 years o age [32–34]. Bu t wh ile sem irigid m aterial can be rem oved with scissor cu ts, a saw is u su ally n eeded or rem oval o plaster casts an d alw ays or rigid syn th etic casts. An addition al m ajor con cern is th e possible carcin ogen ic risk or h ealth care pro ession als w ith requ en t exposu re to sawdu st rom syn th etic casts [35]. 4 3

e ig t o f ca s t s

4 4

Bio m e c a n ics

Mech an ically, plaster ban dages h ave a h igh er elastic m odu lu s an d su bstan tially low er u ltim ate yield stren gth th an syn th etic m aterials [16, 17, 19, 36]. Pressu re in creases in th e so t-tissu e com partm en ts a ter in ju ry an d su rgery [37]. A stu dy com parin g m ore sem irigid casts in patien ts w ith stable, n on displaced ractu res (distal radiu s, scaph oid, an d th m etatarsal or an kle) dem on strated th at patien ts preerred th ese to closed circu m eren tial plaster casts th at w ere m ore rigid th rou gh ou t [38]. 4 5

e co m m e n d a t io n s

Recogn izin g th at, overall, plaster is sti er bu t syn th etic cast m aterial is m ore du rable, th e au th ors o er th e ollow in g clin ical recom m en dation s: • In th e acu te ph ase, directly posttrau m a or postoperatively, u se plaster or im m obilization • In th e secon dary ph ase, u se syn th etic casts [16, 19, 29, 39, 40] • In experien ced caregivers m u st alw ays exercise great cau tion [41]. Sign i can t m orbidity can resu lt rom u se o a rigid circu m eren tial cast or im m obilizin g an extrem ity at risk o sw ellin g. In order to m in im ize th e risks o h arm rom com partm en t syn drom e, pressu re sores, an d/ or com plex region al pain syn drom e, a circu m eren tial cast sh ou ld be split to th e last layer o n on com plian t m aterial an d th en spread apart ar en ou gh to loosen it w h en im m obilizin g a resh in ju ry [41]. Altern atively, in stead o a circu m eren tial cast, a w ell-padded, rigid splin t can be applied w ith com plian t ban dages. Optim izin g com ort, u n ction , an d sa ety in th e in itial cast depen ds on a m u ltitu de o actors [42]. 4 6

Se m irigid ca s t s

Sem irigid below -kn ee w alkin g casts provide greater im m obilization at th e an kle w h ile allow in g m ore ore oot m ovem en t. Th ey are easier to w alk in . Sem irigid castin g h as m easu rable advan tages w h en com pared to rigid syn th etic casts, an d represen ts a u rth er developm en t in th e n on operative m an agem en t o ractu res an d so t-tissu e in ju ries [43]. Casts can be con stru cted w ith a greater degree o u n ction , so th at con trolled m otion an d stabilization can be provided w ith in th e sam e cast [44]. Polyester casts w ith ew er layers are n ot as f exible as so t cast ( berglass) m aterial, bu t h ave n early th e sam e ch aracteristics.

As m en tion ed previou sly, syn th etic cast m aterials are ligh ter th an plaster. How ever, a prospective stu dy recen tly dem on strated th at th e di eren ce in w eigh t w as on ly sign i can t or low er extrem ity casts [31].

4

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

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Sem irigid castin g h as th e best com plian ce an d rate-depen den cy ch aracteristics, accom m odatin g sign i can tly m ore volu m e o f u id com pared to POP or rigid berglass m aterial [49]. Th e u se o sem irigid m aterial m ay th u s be sa er th an oth er m aterials as ar as respon se to sw ellin g (volu m e expan sion ) is con cern ed [49]. Prim ary de n itive care (w h ere treatm en t in volves th e application o on ly on e cast) w ith sem irigid castin g m aterial provides adequ ate su pport or selected low er extrem ity in dication s [29]. Th e prim ary de n itive cast tech n iqu e w ith polyester m aterials h as been practiced or som e tim e [50]. As w ith th e plaster tech n iqu e, th e prim ary de n itive so t cast ban dage sh ou ld also be split com pletely. It is w rapped w ith an elastic ban dage or h eld togeth er w ith velcro straps. An advan tage o th e so t cast tech n iqu e or acu te in ju ries is th at th e split cast can be adju sted to t m ore closely as th e sw ellin g su bsides or m u scles atroph y. A lon gitu din al strip o cast m aterial is rem oved by cu ttin g w ith scissors an d th e cast is “sn u gged” by w rappin g w ith a ban dage. A Coch ran e an alysis ou n d th at th ere is good eviden ce or th e ben e cial e ect o an kle su pports in th e orm o sem irigid orth osis or Aircast braces in order to preven t an kle sprain s du rin g h igh -risk sportin g activities [51].

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Con siderin g also its redu ced cost o application , sem irigid castin g m aterial is an excellen t ch oice or th e in itial sh ortterm im m obilization or th e u n ction al treatm en t o acu te an kle ligam en t in ju ries [52]. In th e postoperative an d con servative care o ligam en t in ju ries to th e an kle join t, sem irigid im m obilization h as been recom m en ded or m an y years [53]. Th e sem irigid cast tech n iqu e allow s m ore u n ction al plan tar f exion / dorsif exion th an oth er an kle casts [54]. Su ch greater m obility o th e an kle w ith in its n orm al ran ge o m otion appears to lead to im proved resu lts w h en an kle sprain s are treated w ith sem irigid casts or orth oses [55].

i

A sem irigid cast sh ou ld be split sim ilarly to rigid casts w h en ever it is applied or an acu te in ju ry. Sin ce a h igh er skin su r ace pressu re h as been m easu red u n der syn th etic casts, an d th e u n split cast can n ot adapt to sw ellin g, som e au th ors advise again st th ese m aterials or acu te in ju ries [19, 45, 46]. Research by Ku n ze an d Haberer sh ow ed th at th e expan sion beh avior o polyester an d polypropylen e is in itially better, w h ile POP sh ow s n o expan sion at all [21], u n less it is split. Typically, th e syn th etic m aterials sprin g back [21]. A ter th e cast is applied, a clear pressu re in crease can occu r u n der con ven tion al plaster ban dages an d syn th etic casts. In an experim en tal stu dy, Davids w as able to sh ow th at sign i can t pressu re in crease occu red u n der rigid berglass casts i w rappin g is carried ou t w ith th e stan dard tech n iqu e [40]. Th e pressu re in crease is greater th an u n der a plaster ban dage [40]. Wh en u sin g th e stretch -relax tech n iqu e (see topic 10 Ban dagin g tech n iqu es in ch apter 14.1 Overview o cast, splin t, orth osis, an d ban dage tech n iqu es) an d sim u lated sw ellin g, th e pressu re valu es are sign i can tly below th e valu es m easu red in side a POP cast [40]. Oth er au th ors su ggest th at th e ch aracteristics o POP an d berglass sh ou ld best be com bin ed [47, 48].

In a com parison o rigid an d sem irigid m aterial, th e ollow in g w as ou n d or grade III lateral collateral ligam en t sprain s o th e an kle: • Th e sem irigid cast grou p h ad a better ran ge o m otion an d cou ld w alk better at th e 2-w eek ch ecku p, bu t th ese di eren ces dim in ish ed at 6 w eeks • With th e sem irigid cast grou p, patien t satis action w as h igh er, n eed or a su pport or w alkin g w as less, an d retu rn to w ork w as earlier.

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Se m irigid ca s t s fo r a cu t e in u rie s —p rim a r d e fin it ive ca re

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Klaus Dre sing, os Engele n

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n d e rca s t m a t e ria ls

In addition to th e stru ctu ral m aterial u sed to bu ild th e cast, tw o kin ds o u n dercast m aterials are typically n eeded: • Tu be ban dages • Cast paddin g. 5 5

Tu e a n d a ge s St o c in e t t e t u e

a n d a ge s

Tu bu lar abric ban dages, o ten called stockin ette, are pu lled over th e skin in order to protect it rom th e cast m aterial an d paddin g. Both n atu ral an d syn th etic textiles are available. Cotton is skin - rien dly, an d m ay also be m ixed w ith rayon or sm all am ou n ts o elastic ber. 5

Tu u la r e la s t ic

a n d a ge s

In tegratin g elastan e (span dex) in to th e abric resu lts in h igh ly com plian t ban dages th at can be applied w ith ou t creases. Th is preven ts slippin g an d con orm s w ell to th e con tou r o th e body. Th e properties o th e paddin g rem ain u n im paired over th e en tire period o w ear. High perm eability in regard to w ater vapor an d air, as w ell as a low absorption volu m e, in crease th e w earer’s com ort. Norm ally, th e kn itted m aterial is sm ooth er on th e ou ter side, th ere ore, th e ou ter side sh ou ld be n ext to th e skin , ie, th e sm ooth er an d so ter side w ill lie directly on top o th e patien t’s skin . In th e n al step o applyin g a tu bu lar elastic ban dage, try to pu ll it in th e direction o h air grow th (ie, dow n , rath er

5

6

Prope rtie s of cast mate rials

th an u p th e leg) in order to avoid leavin g th e skin h airs u n der ten sion . 5

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More cu sh ion in g th an a sin gle layer o stan dard tu be ban dage can be obtain ed by u sin g m aterial w ith a terry-cloth w eave. Th ese terry-cloth stockin ettes are ideal or th e ocu sed rigidity castin g tech n iqu e as w ell as or prim ary de n itive treatm en t. 5

4 S n t e t ic t u e

a n d a ge

Th ese abrics, kn itted in tu bes, are su itable or u se w ith syn th etic or POP castin g m aterials. Som e o th e stockin ettes h ave breath able properties, an d som e are w ater-repellen t. 5

is also n ot w aterproo . Th e requ ired sizes can be cu t ou t o bigger packages. How ever, in som e cou n tries, th e ch oice betw een cotton an d syn th etic paddin g is severely lim ited, w ith syn th etic paddin g m aterial eith er n ot available at all or restricted to special application s an d treatm en ts. 5

S n t e t ic p a d d in g

Un like cotton paddin g, syn th etic paddin g o ten com es in th e orm o n on absorben t (yet h igh ly breath able) m aterial th at w icks m oistu re aw ay rom th e skin an d redu ces th e risk o skin m aceration . Som e syn th etic paddin g m aterials are even design ed to be com pletely w ater resistan t, in w h ich case, i a syn th etic cast is also u sed, patien ts can sh ow er or sw im w h ile w earin g casts w ith th is paddin g, alth ou gh air dryin g, perh aps w ith a cool h airdryer, is advised.

Ca s t p a d d in g

Orth opedic paddin g is u sed u n der a plaster or syn th etic cast or protection o th e skin , so t tissu es, bon y prom in en ces, an d su per cial n erves, an d protects th em rom pressu re, u lceration , an d abrasion w h ile w earin g th e cast as w ell as du rin g cast rem oval. Paddin g also h elps protect th e skin rom th erm al in ju ry du rin g cast h arden in g. Gen tly com pressed u n dercast paddin g can h elp preven t edem a. Cast paddin g is available in m an y varieties. Th e m ost com m on cast paddin gs are rolled th in cotton (or viscose), w h ich is readily stretch ed or torn by h an d, an d syn th etic paddin g su ch as polyester. Sh eet w addin g (th e battin g/ paddin g m ade or qu ilts) or oth er th ick, com pressible ber sh eets h ave also been u sed exten sively. Con orm able rolls are easiest to apply. Felt pads can be added in order to protect pressu re poin ts, an d som e syn th etic m aterials are w aterproo [5]. Gen erally, th e au th ors recom m en d syn th etic cast paddin g. Poorly applied paddin g can produ ce sores, an d too m u ch paddin g resu lts in an ill- ttin g cast, poorer im m obilization , an d possibly im paired h ealin g. Excessive paddin g th ickn ess h as been associated w ith secon dary ractu re displacem en t [56]. In cases w ith redisplacem en t, th e plaster m oldin g (cast in dex) an d paddin g (paddin g in dex) w ere ou n d to be sign i can tly greater [57].

Pol e ste r

Th e m ost com m on ly u sed syn th etic cast paddin g is ban dage m ade o low or n on absorben t crin kled polyester bers. Polyester paddin g acilitates application by requ irin g on ly a little ten sion on th e abric as it is rolled on to th e lim b, w ith som e gen tle sm ooth in g w ith th e oth er h an d. Th e cu sh ion in g e ect is m ain tain ed even u n der pressu re an d w h en m oist. It stays perm eable to air an d perspiration . Th e m aterial h as a tem peratu re-com pen satin g e ect an d is easy to h an dle. Du rin g application it can easily be torn by h an d as n eeded. Sterilization by au toclavin g at 121° C is possible. Th e m aterial is radiolu cen t. Pol acr late

Th is m aterial is u sed or partial paddin g at th e edges o th e cast or w eigh t-bearin g zon es. In dividu ally cu t sh apes are u sed to protect exposed su pport zon es w h en applyin g tru n k or pelvis/ leg casts. Polyacrylate paddin g m ostly u ses an adh esive backin g, allow in g th e paddin g to be applied in strips. It in volves a n ely-porou s oam , w h ich provides good air perm eability an d h igh skin toleran ce.

A su cien t layer o paddin g sign i can tly protects th e skin du rin g cast rem oval, w h en th e blade o th e oscillatin g cast saw grow s h ot, an d can protect again st m ech an ical in ju ries (laceration s or abrasion s) [58]. Clearly, th e skill u l application o paddin g is as essen tial as plaster m oldin g in th e produ ction o a sa e an d e ective th erapeu tic cast ( ig 6 ). 5

Co t t o n p a d d in g

Cotton paddin g is so t on th e skin bu t is n ot very m oldable an d m ay resu lt in lu m ps an d/ or ru ptu res o th e m aterial. It

6

ig 6 The s illful application of cast padding is e sse ntial in the production of a safe and e ffe ctive the rape utic cast

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Closed-cell oam paddin g exists, an d is occasion ally u sed as a sports protection , bu t is n ot recom m en ded in castin g as it m ay con tain ru bber latex, w h ich can cau se allergic reaction s. e lt

Needle- elt paddin g, both w ith or w ith ou t an adh esive backin g, is an orth opedic elt u sed or addition al patien t com ort in splin tin g an d castin g tech n iqu es. Th is elt m ay be com bin ed w ith oam or addition al protection an d cu sh ion in g.

3 Pa d d in g a n c o ra ge

Cre pe pape r

Crepe paper ban dages are m ade o w ood- ree, n e crepe paper, u sed as a barrier betw een th e dry paddin g an d th e w et POP. Th ey are h igh ly exten sible, an d easy to apply an d to tear o ; o ten th e en d o th e ban dage is sligh tly asten ed w ith latex adh esive. Th ey are sligh tly w ater resistan t. Su ch m aterials m ay prove con strictin g i th e cast is adju sted a ter its application (eg, cast w edgin g). S nthe tic rolle r bandage s

Polyu reth an e ban dages are o ten u sed in stead o crepe paper. Th ey are breath able an d slip resistan t.

Elastic foam tape

Adh esive elastic oam tape provides so t edges or casts an d splin ts, or protection or bon y prom in en ces ( ig 6 ). It is particu larly u se u l or th e edgin g o rem ovable casts an d orth oses. Th e cen tral h igh -stretch section m akes it easy to old over cast edges. It sh ou ld be as th in as possible to avoid redu cin g stability.

Tape s, clips, and othe r fixing m ate rials

A special kn it stru ctu re lets w ater qu ickly drain rom th e cast (30–60 m in u tes). Most o th e liqu id ru n s ou t o th e cast,

Du rin g th e process o m akin g th e cast, or to h old th e paddin g or cast in place, a variety o xation m aterials m ay be requ ired. For exam ple, gau ze an d elastic ban dages are u sed to w rap an d h old an open ed (split) cast in place. Wrapped ban dages are o ten secu red by u sin g su rgical tape, adh esive tape, elastic clips, or sa ety pin s (see ch apter 18 Su pport ban dages). An d h ook (scratch y) an d loop (sm ooth ) strips o velcro allow a splin t or orth osis to be tem porarily rem oved an d reapplied later (eg, or bath in g or ph ysioth erapy).

ig 6 Ope n poure d adhe sive foam padding provide s additional prote ction to the s in and bon prom ine nce s

ig 6 Elastic foam tape , use d for the e dge s of casts or to prote ct bon prom ine nce s

ate rproof padding

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All paddin g m aterial sh ou ld be an ch ored in som e w ay in order to avoid sh i tin g u n der th e cast. Extra pads can also be placed so th ey are in con tact w ith th e cast m aterial to w h ich th ey are likely to adh ere.

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Polyu reth an e h as been ou n d to be h igh ly e ective in preven tin g pressu re sores [59].

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A ban dage w ith an open -pored (open -cell) su r ace m ade ou t o polyu reth an e oam ( ig 6 ) provides addition al protection to th e skin , an d is particu larly su ited or u se on bon y prom in en ces. Foam paddin g sh ou ld be u sed w ith an adh esive backin g on on e side, as th is w ill adh ere to th e tu be ban dage (stockin ette), h oldin g it in place an d avoidin g m ovem en t in side th e cast. It is typically air an d m oistu re perm eable an d resistan t to perspiration .

th e rest evaporates th rou gh th e cast h eated by body tem peratu re. Water-perm eable lin ers allow tran spiration to escape rom th e cast. Especially in ch ildren , th ese lin ers m ay preven t skin irritation [60].

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Pol ure thane adhe sive foam padding

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Prope rtie s of cast mate rials

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Su m m a r

• Plaster o Paris is th e gold stan dard or acu te n on operative trau m a care, especially w h en redu ction is requ ired; it is available w orld w ide • Syn th etic cast m aterial is m ore com ortable, ligh ter in w eigh t, an d m ore stable th an POP, bu t is m ore expen sive • A ter h arden in g, sem irigid (so t) syn th etic m aterial is f exible, bu t lacks elasticity • Un like rigid syn th etics, sem irigid m aterials do n ot n eed a cast saw or rem oval • Ph ysician s / cast tech n ician s sh ou ld en su re th ey are u lly aw are o th e application w orkin g tim e, settin g tim e (be ore h arden in g), an d h eat gen eration cau sed by both POP an d syn th etic castin g m aterials, as in correct application can low er th e cast’s e ectiven ess or cau se poten tial h arm • Un der each cast, tu be ban dages (stockin ette) an d paddin g are applied to protect th e skin an d so t tissu es • Th ere are a w ide ran ge o oth er sim ilarities an d di eren ces betw een plaster o Paris an d syn th etic castin g m aterials; see Ta le 6 or a com parison su m m ary.

tem

Plaster of Paris P P

Water resistance

–

Rigid synthe tic material

Semirigid syn thetic material

scillating cast saw

Scissors

Perspiration transfer Skin irritation during application emoval tools

scillating cast saw

Gloves necessary

–

xothermic reaction during application

–

Weight adiolucency

–

Fast hardening speed Immediate weight bearing

–

Conformability ulkiness

–

–

–

–

High

edium-high (semirigid combicast)

Stability esistance against tension

–

esistance against compression Acute fracture care aintains reduction ffers support and functional stabili ation Thickness olding properties Strength-to-weight ratio

Low

Allows for a primary definitive cast

e ge nd for Table Nil or not applicable Slightl applicable Mode rate l applicable Strongl applicable Ta le 6

Sum mar of cast m ate rial prope rtie s

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

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Klaus Dre sing, os Engele n

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e fe re n ce s Evalu ation o berglass versu s plaster o Paris or im m obilization o ractu res o th e arm an d leg. Mil Med. 2002 Au g; 167(8):657–661. 32. a t , o ge lm a n , t t ia s , e t a l . An xiety reaction in ch ildren du rin g rem oval o th eir plaster cast w ith a saw. J Bone Joint Surg Br. 20 01 Apr; 83(3):388 –390. 33. Ca rm ic a e l , e s t m o re la n d . E ectiven ess o ear protection in redu cin g an x iety du r in g cast rem oval in ch ild ren . Am J Orthop (Belle Mead NJ). 2005 Jan ; 34(1):43 –4 6. 34. iggin s C , Bro n . Hear in g protection an d cast saw n oise. J South Orthop A ssoc. 1996 Sprin g; 5(1):14. 35. a lla g e r P, Ba d i C , in c a m S, e t a l . Ch em ical exposu res, m edical h istor y, an d risk o squ am ou s an d basal cell carcin om a o th e sk in . Cancer Epidemiol Biomarkers Prev. 1996 Ju n ; 5(6):419 –424. 36. Ca lla a n , Ca rn e , a d d a rio N, e t a l . A com parative stu dy o syn th etic cast m aterial stren gth . Orthopedics. 1986 May; 9(5):679 –681. 37. re s in g , Pe t e rs o n T, Sc m it Ne u e r u rg P. Com partm en t pressu re in th e car pal tu n n el in distal ractu res o th e radiu s. A prospective stu dy. Arch Orthop Trauma Surg. 1994; 113(5):285 – 289. 38. Co e n P, S a . Focu sed rigid ity castin g: a prospective ran dom ised stu dy. J R Coll Surg Edinb. 20 01 Oct; 4 6(5):265 – 270. 39. Bo e r P, Po e ll S . A clin ical evalu ation o plaster-o -Paris an d eigh t syn th etic ractu re splin tin g m ater ials. Injury. 1992; 23(1):13 –20. 40. a vid s , ric S , S e e s , e t a l . Sk in su r ace pressu re ben eath an above-th e-k n ee cast: plaster casts com pared w ith berglass casts. J Bone Joint Surg Am. 1997 Apr; 79(4):565 –569. 41. B le r . [The Treatment o Fractures]. Vol 1 an d 2. 11th ed. Wien : Wilh elm Mau drich ; 1943. Germ an . 42. Sp a in . Castin g acu te ractu res. Part 1—Com m on ly asked qu estion s. Aust Fam Physician. 200 0 Sep; 29(9):853 –856. 43. it e , Sc u re n , o n n . Sem irigid vs r igid glass bre castin g: a biom ech an ical assessm en t. Clin Biomech (Bristol, Avon). 2003 Jan ; 18(1):19 –27. 4 4. it e , Sc u re n , a rd la , e t a l. Biom ech an ical assessm en t o gait in below-kn ee walk in g casts. Prosthet Orthot Int. 1999 Au g; 23(2):142 –151.

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17. Ca lla a n , a d d a rio N, illia m s S, e t a l . Th ree ex perim en tal design s testin g orth opedic castin g m aterial stren gth . Orthopedics. 1986 May; 9(5):673 –675. 18. Ca lla a n , a rris B . Sh ort h istor y o plaster-o -Paris cast im m obilization . Minn Med. 1986 Apr; 69(4):195 –196. 19. e . Plaster u ses an d m isu ses. Clin Orthop Relat Res. 1982 Ju l; (167):242 –249. 20. o u n ge r S, Cu rra n P, c u e e n . Backslabs an d plaster casts: wh ich w ill best accom m odate in creasin g in tracom partm en tal pressu res? Injury. 1990 May; 21(3):179 –181. 21. u n e , a e re r . [Com parative stu d ies o syn th etic an d n on syn th etic cast dressin gs]. Un allchirurg. 1994 Ju n ; 97(6):325 –331. Germ an . 22. i a l o , Be a u d o in , ra u s e . Mech an ical properties an d m aterial ch aracteristics o orth opaed ic castin g m aterial. J Orthop Trauma. 1989; 3(1):57–63. 23. a rt in e , Sa rm ie n t o , a t t a . Closed ractu res o th e prox im al tibia treated w ith a u n ction al brace. Clin Orthop Relat Res. 2003 Dec; (417):293 – 302. 24. Sa rm ie n t o , a go rs i B, c , et a l . Fu n ction al bracin g or th e treatm en t o ractu res o th e hu m eral d iaph ysis. J Bone Joint Surg Am. 200 0 Apr; 82(4):478 –4 86. 25. Sa rm ie n t o , a t t a . 450 closed ractu res o th e d istal th ird o th e tibia treated w ith a u n ction al brace. Clin Orthop Relat Res. 2004 Nov; (428):261– 271. 26. St e a rt , In n e s , Bu r e . Fu n ction al cast-bracin g or Colles’ ractu res. A com parison between cast-bracin g an d con ven tion al plaster casts. J Bone Joint Surg Br. 1984 Nov; 66(5):749 –753. 27. Sc u re n . Working with So t Cast— a Manual on Semi-rigid Immobilisation. 2n d ed. Borken , Germ an y: 3M M in n esota M in in g & Man u actu rin g; 1994:9 –29. 28. C a llis , e ls , u ll , e t a l. E ect o cyclic pn eu m atic so t tissu e com pression on simu lated d istal radiu s ractu res. Clin Orthop Relat Res. 2005 Apr; (433):183 –188. 29. Sc le i is . [Gypsum and Synthetic Cast. Conventional Fixation and Functional Stabilization]. 2n d ed. Darm stadt: Stein kop Verlag; 2006. Germ an . 30. C a rn le . The Closed Treatment o Common Fractures. 4th ed. Un ited Kin gdom . Cam bridge Un iversity Press; 2010.

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1. Sa m p s o n e d . Gypsum: Properties, Production and Applications (Chemical Engineering Methods and Technology). 1st ed. Hau ppau ge: Nova Scien ce Pu b In c; 2011. 2. Po va cs . [History o Trauma Surgery]. 2n d ed. Heidelberg: Sprin ger Medizin Verlag; 2007. Germ an . 3. Co ld it C. Plaster o Paris: th e orgotten h an d splin tin g m aterial. J Hand Ther. 2002 Apr-Ju n ; 15(2):14 4 –157. 4. u re vit S, T t iu m , a lp e rin C, e t a l . Correlation between experien ce in plaster-cast application an d weigh t o plaster o Paris. Eur J Orthop Surg Traumatol. 20 04; 14(2):72 –74. 5. a la n s i , No o n a n . Cast an d splin t im m obilization : com plication s. J Am Acad Orthop Surg. 2008 Jan ; 16(1):30 – 40. 6. St e a rt T, C e o n g , Ba rr , e t a l . Stron g an d ligh t plaster casts? Injury. 2009 Au g; 40(8):890 –893. 7. tc , o s s N, a rd la . Glass bre versu s n on -glass bre splin tin g ban dages. Injury. 1992; 23(2):101–106. 8. Nie ls e n , ic e t t s . Wh ere to split plaster casts. Injury. 20 05 May; 36(5):588 –589. 9. Sc m id t , So m e rs e t , Po rt e r . Mech an ical properties o orth oped ic plaster ban dages. J Biomech. 1973 Mar; 6(2):173 –185. 10. a n n a a , u n t e r . Th erm al e ects o castin g m aterials. Clin Orthop Relat Res. 1983 Dec; (181):191–195. 11. a la n s i , a la n s i , a , e t a l. Th erm al in ju ry w ith con tem porar y cast-application tech n iqu es an d m eth ods to circu m ven t m orbid ity. J Bone Joint Surg Am. 2007 Nov; 89(11):2369 –2377. 12. a va le t t e , Po p e , ic s t e in . Settin g tem peratu res o plaster casts. Th e in f u en ce o tech n ical variables. J Bone Joint Surg Am. 1982 Ju l; 64(6):907–911. 13. Po p e , Ca lla a n , a va le t t e . Settin g tem peratu res o syn th etic casts. J Bone Joint Surg Am. 1985 Feb; 67(2):262 –26 4. 14. m e d SS, Ca rm ic a e l . Plaster an d syn th etic cast tem peratu res in a clin ical settin g: an in vivo stu dy. Orthopedics. 2011 Jan ; 34(2):99. 15. n a l S, so , ilm a C, e t a l . Th ird-degree bu rn a ter plaster o Paris brace. Plast Reconstr Surg. 200 4 Nov; 114(6):1686 –1687. 16. Be rm a n T, Pa r s B . A com parison o th e m ech an ical properties o berglass cast m aterials an d th eir clin ical relevan ce. J Orthop Trauma. 1990; 4(1):85 –92.

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45. o in S , o o d B. Early so t-tissu e com plication s a ter ractu res o th e d istal part o th e radiu s. J Bone Joint Surg Am. 1993 Jan ; 75(1):14 4 –153. 46. a rs o n B , e e n a n . Sk in su r ace pressu res u n der sh ort leg casts. J Orthop Trauma. 1993; 7(3):275 –278. 47. P il in T , it t in s . Hybrid casts: a com par ison o di eren t castin g m aterials. J Am Osteopath A ssoc. 1999 Ju n ; 99(6):311–312. 48. C a rle s N, e n . Properties o a h ybrid plaster- breglass cast. Can J Surg. 2000 Oct; 43(5):365 –367. 49. e s p a n d e S . An ex per im en tal stu dy o pressu re-volu m e dyn am ics o castin g m aterials. Injury. 20 05 Sep; 36(9):1067– 1074. 50. Sc le i is . [ Fractu re xation w ith polyester. Prim ary care w ith polyester in selected orm s o ractu res]. Pf ege Z. 1994; 47(12):66 4 –665. Germ an . 51. a n d o ll , o e B , u in n , e t a l. In terven tion s or preven tin g an k le ligam en t in ju ries. Cochrane Database Syst Rev. 20 01; (3):CD000 018.

52. vci S, Sa li . Com parison o th e resu lts o sh ort-term rigid an d sem irigid cast im m obilization or th e treatm en t o grade 3 in version in ju ries o th e an k le. Injury. 1998 Oct; 29(8):581–58 4. 53. Ne u ge a u e r , a s c in g , a lle n c . [ Ex perien ces w ith u sin g th e so t cast in in ju ries o th e bu lar ligam en t o th e u pper an k le join t]. Un allchirurg. 1995 Sep; 98(9):489 –492. Germ an . 54. Nis i a a T, u ro s a a , i u n o , e t a l . Protection an d per orm an ce e ects o an k le bracin g. Int Orthop. 200 0; 24(5):285 –288. 55. o s c , e o m P, Sc m a l T, e t a l . [ Fu n ction al resu lts o dyn am ic gait an alysis a ter 1 year o h obby-ath letes w ith a su rgically treated an k le ractu re]. Sportverletz Sportschaden. 2002 Sep; 16(3):101–107. Germ an . 56. Sin g S, B a t ia , o u s d e n P. Cast an d padd in g in d ices u sed or clin ical decision m ak in g in orearm ractu res in ch ildren . Acta Orthop. 20 08 Ju n ; 79(3):386 –389.

57. B a t ia , o u s d e n P . Redisplacem en t o paed iatric orearm ractu res: role o plaster m ou ld in g an d padd in g. Injury. 2006 Mar; 37(3):259 –268. 58. S u le r , ris a N . Cast-saw bu rn s: evalu ation o skin , cast, an d blade tem peratu res gen erated du rin g cast rem oval. J Bone Joint Surg Am. 20 08 Dec; 90(12):2626 –2630. 59. o rn i C, o ro , Tre m o s in i , e t a l . Use o polyu reth an e oam in side plaster casts to preven t th e on set o h eel sores in th e popu lation at risk: a con trolled clin ical stu dy. J Clinical Nursing. 2011 March ; 20(5):675 –680 60. ru s e , ra cc ia , Bo o s , e t a l . Goretex abric as a cast u n derlin er in ch ildren . J Pediatr Orthop. 1991 Nov– Dec; 11(6):786 –787.

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

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Socioeconomic considerations Klaus Dre sing, im

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In t ro d u ct io n va ila ilit a n d d is t ri u t io n

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Price s a n d co s t s Dire ct and indire ct costs Casting te chni ue s Inte rnational AO surve

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Authors

Klaus Dre sing, im

arrison

Socioeconomic considerations

va ila ilit a n d d is t ri u t io n

Th e availability o cast su pplies or th e pro ession al u ser depen ds largely u pon th e local distribu tion system . Th e speci c bran ds o plaster, syn th etic cast m aterials, cast paddin g, tu bu lar ban dages, an d oth er su pplies w ill alm ost de n itely be determ in ed by th e distribu tors in a given region . Most m an u actu rers u se distribu tors in stead o sellin g an d deliverin g directly to pu rch asers, w h o m igh t be in dividu al practition ers, sm all m edical su pply m erch an ts, clin ics, h ospitals, pu rch asin g cooperatives, region al h ealth care system s, or govern m en tal u n its, ran gin g u p to a m in istry o h ealth or n ation al govern m en t.

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Plaster o Paris cast m aterial is available in m ost m edical acilities, w orldw ide. Syn th etic m aterials m ay be h arder to n d, especially in less developed cou n tries. Th e m arket or cast m aterials is n ot stable. As described in ch apter 6 Properties o cast m aterials, th ere is a w ide ran ge o syn th etic cast ban dages, w ith a variety o properties an d pu rposes. Th ey are o ten described by u se o th eir bran d n am es, w ith ou t w h ich th e exact produ ct m ay be di cu lt to iden ti y. Plaster o Paris (POP), sim ilarly, is sold u n der a variety o bran d n am es. Availability is region al. Preparation s are n ot iden tical, an d u sers readily distin gu ish di eren ces an d exh ibit pre eren ces [1]. Wh ile th e w idth s o plaster ban dages are m ore or less stan dard in eith er cen tim eters (eg, 5, 7.5, 10, 15, an d 20 cm ) or in ch es (eg, in US & som etim es in Can ada: 2, 3, 4, 5, 6, an d 8 in ch es), len gth s o POP ban dage rolls vary, so th at equ ivalen ce can n ot be presu m ed. It appears th at m aterials or syn th etic casts are at least as variable as th ose or POP. Bran d n am es ch an ge occasion ally, an d produ cers an d distribu tors com e an d go. Produ cers m ay w ork locally as w ell as or larger m arkets. Recen tly, several n ew produ cers o cast m aterials h ave open ed or bu sin ess in In dia an d Ch in a. It seem s likely th at prices, availability, h an dlin g qu alities, an d oth er properties w ill con tin u e to ch an ge or th e oreseeable u tu re.

Th e costs o cast m aterials are n ot con sisten t, even in a sin gle cou n try. Prices paid or m edical su pplies are a ected by th e local distribu tion system , in clu din g delivery an d storage, qu an tity pu rch ased, an d in dividu ally n egotiated con tracts betw een su ppliers an d pu rch asers. In som e settin gs, qu ality con trol o su pplies du rin g sh ippin g, w areh ou se storage, delivery, an d on -site storage is an im portan t issu e. Wh ile poorly packaged POP, w ith poten tial to becom e u n u sable du rin g storage, m ay h ave a low er pu rch ase price, it cou ld prove sign i can tly m ore expen sive per treatm en t. Fu rth erm ore, expen ses are gen erated by su ppliers’ e orts to preserve resh n ess an d qu ality. Produ ct sh el -li e m ay be a particu larly sign i can t issu e in tropical en viron m en ts. Practition ers m u st w ork closely w ith pu rch asin g agen ts in order to obtain optim al valu e in relation to pu rch ase price.

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Wh ile local “list prices” or cast su pplies can be obtain ed rom th e in tern et or oth er sou rces, th e actu al cost to th e pu rch aser as w ell as ch arges to th e patien ts vary w idely, an d are som etim es n ot even closely related or are di cu lt to obtain . Medical costs an d ch arges gen erally orm a com plex relation sh ip. Depen din g u pon th e practice settin g (h ospital, clin ic, su rgeon ’s o ce, etc) an d th e local arran gem en ts or h ealth care delivery an d its reim bu rsem en t, di eren t costs w ill be qu oted or m aterials, labor, an d acility u se. A sin gle ch arge cou ld be set or a given type o cast, w ith or w ith ou t a separate allow an ce or m aterials. Takin g all th ese issu es in to con sideration , it is easy to u n derstan d h ow di cu lt it is to com pare th e costs o casts rom on e site o care to an oth er. Non eth eless, th e practition er m u st ch oose th e m ost appropriate cast m aterial or each patien t rom w h at is available. In addition to th e practition er’s pre eren ce (eg, h an dlin g ch aracteristics), th e cost an d com parative e ectiven ess m u st also be con sidered.

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In assessin g costs o m aterials, it is im portan t to be aw are o region al di eren ces, as th ese m igh t be h elp u l in n egotiation s or better prices. It is also im portan t to con sider all costs in volved, both direct an d in direct. Direct costs n ot on ly in clu de th e su pplies th at are u sed bu t also costs related to h u m an resou rces, in clu din g train in g, tim e requ ired or th e en tire service, an d th e n ecessary in rastru ctu re to m ain tain an d stock an adequ ate acility. In direct costs in clu de tim e an d oth er costs or patien ts an d th eir su pporters. For exam ple, i a particu lar ch oice o cast n eeds to be replaced m ore o ten du rin g th e treatm en t process, both direct an d in direct costs o care w ill in crease. Th u s, in th e lon g ru n , a m ore expen sive cast m aterial requ irin g ew er ch an ges or revision s m ay tu rn ou t to be less expen sive, particu larly w h en th e overall costs are con sidered in stead o m aterial costs alon e. In 1997, Dow n in g et al ou n d th at th e cost to th e h ospital or treatin g diaph yseal tibia ractu res in th e UK w as low er w h en u sin g plaster casts th an w ith in tram edu llary n ails, bu t th at th e overall cost to th e com m u n ity w as essen tially th e sam e [2]. How ever, a soph isticated an alysis is n eeded in order to com pu te su ch costs. In a stu dy o treatm en ts or scaph oid ractu res, Vin n ars et al dem on strated th at, w h en retu rn to w ork w as taken in to con sideration , th e in direct costs w ere low er in n on m an u al w orkers sin ce th ey h ad sh orter periods o disability [3]. Few com preh en sive an alyses o th e costs o casts or extrem ities h ave been pu blish ed. Th ose available are lim ited in exten t an d rarely u p-to-date. Th ey m ay n ot ref ect cu rren t pricin g, available m aterials, an d clin ical practice. No pu blication cou ld be iden ti ed th at addresses th e person n el costs (tim e, labor, train in g, etc) o cast application . 3

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Several observation s h ave been m ade regardin g th e cost o casts. It is clearly n ecessary to con sider th e total cost o cast treatm en t or th e typical treatm en t du ration . For exam ple, a 2002 stu dy in th e USA reported th e m aterial cost or a POP sh ort arm cast (elbow to n ger) as $12.90 versu s $15.40 or a sim ilar cast m ade u sin g berglass [4]. How ever, less expen sive cast m aterial, typically POP, can be less du rable an d requ ire replacem en t m ore requ en tly [5, 6]. Th ere ore, a cast th at can be adju sted in stead o n eedin g to be replaced m igh t be m ore cost-e ective.

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A recen t stu dy rom Göttin gen , Germ an y, com pared tw o di eren t castin g tech n iqu es or u pper- an d low er-extrem ity in dication s [7]. Th e rst tech n iqu e (ie, con ven tion al) in volved in itial u se o a POP cast, rou tin ely ollow ed by a ch an ge to a rigid syn th etic cast. Th e secon d tech n iqu e (ie, prim ary de n itive) starts ou t w ith a sem irigid syn th etic cast, rein orced w ith addition al rigid splin t lon gu ettes. Th is in itial cast w as split a ter bein g applied an d secu red w ith an elastic ban dage or velcro tape. In stead o replacin g th is prim ary de n itive cast, it w as sim ply tigh ten ed on ce sw ellin g resolved, rem ovin g som e o th e m aterial alon g th e split, i n ecessary. Th e tim e requ ired, person n el costs (bu t n ot th e ph ysician ’s), an d th e cost o m aterials w ere com pared. Th e secon d (ie prim ary de n itive) tech n iqu e w as ou n d to be less expen sive by u p to 30% [7]. Fu rth erm ore, prim ary de n itive sem irigid casts are m ore com ortable or patien ts, requ ire less paddin g, an d are even applicable or som e in dication s in volvin g th e h an d an d n gers [6]. Th e am ou n t o m aterial u sed to apply a given cast can vary sign i can tly based n ot on ly u pon th e m aterial ch osen bu t u pon th e tech n iqu e o cast application , th e size o th e patien t, an d local cu stom s. Typically, m ore layers o POP are requ ired to obtain a cast o desired stren gth an d du rability com pared w ith berglass-based syn th etic. Use o a com posite cast, in w h ich th e in itial layers o cast m aterial are POP bu t th e ou tside is a stron ger syn th etic, resu lt in greater stren gth an d low er overall m aterial cost. Use o splin t ribs on con vex su r aces, in stead o addition al circu m eren tial layers o a cast ban dage roll, in creases stren gth an d du rability w ith ou t addin g as m u ch m aterial, th u s redu cin g cost an d w eigh t [8]. 3 3

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s u r ve

In tern ation ally, com parative price in orm ation or cast m aterials is n ot readily available. Th ere ore, in Septem ber 2011, a su rvey am on g AO su rgeon s rom variou s parts o th e w orld w as carried ou t speci cally or th is pu blication . In orm ation on person n el costs w as n ot requ ested. Th e su rvey speci cally addressed th e cost o m aterials bu t n ot speci c bran ds, types o syn th etic cast m aterials, actu al sizes o speci ed rolls, or th e am ou n t o m aterial u sed per typical cast. Alth ou gh relevan ce to th e reader' s situ ation w ill vary, th e resu lts are presen ted in order to provide an exam ple o th e variability o th e costs o m aterials.

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

arrison

presen ts th e resu lts o th e global su rvey o AOTrau m a su rgeon s. Th e cost an alysis is based on th e in orm ation su pplied by 77 AOTrau m a m em bers, w ith prices con verted rom th eir origin al cu rren cy to Eu ros (€). Un ortu n ately, n o in orm ation w as obtain ed or North Am erica. Ta le

1.05

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1.78

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6.93

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7.5 cm x 30 cm

8.06

Ta le Ave rage costs of casting m ate rials surve of Traum a me m be rs

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A spreadsh eet h as been developed so th at th e reader can do th eir ow n local or region al calcu lation o th e estim ated costs o a cast procedu re. Th is is available on th e Th iem e Media Cen ter w ebsite.

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0.91

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1.30

2.46

1.56

1.67

1.38

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0.81

0.89

0.81

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7.5 cm x 3.6 m

4.87

27.73

7.59

7.38

4.95

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4.60

14.51

7.83

8.06

12.62

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• Castin g m aterials an d services com prise a ran ge o direct an d in direct costs th at vary greatly arou n d th e w orld • Th e cost o m aterials u sed is a ected by a w ide ran ge o actors, su ch as types o su ppliers, m aterial qu ality an d storage, even to th e in dividu al tech n iqu e o th e caregiver • Th e cost o an in dividu al POP cast is typically low er th an th at u sin g syn th etic cast m aterial, h ow ever, th e latter is m ore du rable an d does n ot n eed to be replaced as o ten • Wh en th e expen se o cast room person n el is taken in to con sideration , th e overall costs o syn th etic casts is o ten less becau se each cast lasts lon ger an d, m oreover, it is possible to u se a sem irigid syn th etic cast or th e in itial im m obilization , w h ich can th en be adju sted, rath er th an replaced, or a proper t a ter th e early sw ellin g h as resolved (prim ary de n itive tech n iqu e).

e fe re n ce s

1. Cre s e ll T, lo e rs , Ba r t o n , e t a l . Sta opin ion s on castin g m aterial bran ds: a prospective stu dy. Injury. 2008 Dec; 39(12):14 67–1473. 2. o n in g N , rif n , a vis T . A com parison o th e relative costs o cast treatm en t an d in tram edu llary n ailin g or tibial d iaphyseal ractu res in th e UK. Injury. 1997 Ju n –Ju l; 28(5 –6):373 –375. 3. in n a rs B, e n s t a m , e rd in B. Com parison o d irect an d in d irect costs o in tern al xation an d cast treatm en t in acu te scaph oid ractu res: a ran dom ized trial in volvin g 52 patien ts. Acta Orthop. 2007 Oct; 78(5):672–679. 4. o a ls i , Pit c e r r, Bic le B. Evalu ation o berglass versu s plaster o Paris or im m obilization o ractu res o th e arm an d leg. Mil Med. 2002 Au g; 167(8):657–661. 5. a rs a ll P , i le , a lt e rs T , e t a l . Wh en sh ou ld a syn th etic castin g m aterial be u sed in pre eren ce to plaster-o -Par is? A cost an alysis an d gu idan ce or castin g departm en ts. Injury. 1992; 23(8):542 –54 4. 6. Sc le i is . [Plaster and Synthetic Casts: Conventional Fixation and Functional Stabilization]. 2n d ed. Darm stadt: Stein kop Verlag; 2006. Germ an . 7. re s in g , Sc le i is , St rm e r . [ Prim ar y de n itive cast th erapy on th e u pper an d lower extrem ities. In d ication s an d cost an alysis]. Chirurg. 2009 Mar; 80(3):223 –230. Germ an . 8. T e o p o ld C, Bu s , ils o n S , e t a l . Optim al plaster con orm ation derived u sin g a cu stom -m ade jig to obtain m aximu m stren gth o protective plaster o Paris or h an d su rgery. J Trauma. 2007 Nov; 63(5):1074 –1078.

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Outcomes after nonoperative fracture treatment—what information can be gained from evidence based medicine anson, Klaus Dre sing

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Outcome s afte r nonoperative fracture tre atment—what information can be gaine d from e vide nce base d me dicine

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Authors

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a t is e vid e n ce a n d ca re

is it n e e d e d in fra ct u re

Th e balan ced application o th e eviden ce in clin ical decision m akin g is th e cen tral poin t o practicin g eviden ce-based orth opedics, an d in volves, accordin g to eviden ce-based m edical prin ciples, a com bin ation o th e su rgeon ’s clin ical expertise an d ju dgm en t, th e patien t’s perception s an d social valu es, an d th e best available research eviden ce. Eviden ce-based orth opedics (EBO) in volves care u l atten tion to th e design , statistical an alysis, an d critical appraisal o clin ical research . Th e delin eation betw een “ou tcom es” research an d “eviden ce-based m edicin e” (EBM) is vagu e. Sin ce th e term eviden ce-based m edicin e w as coin ed, orth opedic su rgeon s an d research ers h ave adopted th eir ow n style o critical appraisal, o ten coin ed as “eviden ce-based orth opedics”. Th ey u se a clear delin eation o relevan t clin ical qu estion s, a th orou gh search o th e literatu re relatin g to th e qu estion s, a critical appraisal o available eviden ce an d its applicability to th e clin ical situ ation , an d n ally, th e balan ced application o th e con clu sion s to th e clin ical problem [1, 2]. Gain in g m om en tu m rom th e global EBM m ovem en t, th e con cepts an d ideas attribu ted to an d labeled collectively as EBO h ave becom e a part o daily clin ical rou tin e. Su rgeon s h ear m ore an d m ore abou t eviden ce-based gu idelin es, eviden ce-based care path s, an d eviden ce-based qu estion s an d solu tion s. Th e con troversy h as sh i ted rom w h eth er to

Given th e in creasin g bu rden rom to th e risin g n u m ber o pu blication s, su rgeon s m u st be able to distin gu ish h igh erqu ality stu dies rom low er-qu ality stu dies in order to en su re in orm ed clin ical practice. In orth opedic literatu re, variou s classes o stu dies exist, in clu din g stu dies o th erapy, progn osis, diagn osis, an d econ om ic an alysis. Th ese di eren t classes o stu dies all h ave th eir in dividu al h ierarch ies o eviden ce. Given th at th e m ajority o orth opedic literatu re con sists o th erapeu tic stu dies, ocu s on th e levels o eviden ce or a su rgical th erapy is typically th e n orm . Th erapeu tic stu dies are th ose in vestigatin g th e e ect o a treatm en t or in terven tion . Th ese stu dies, w h ich best m in im ize bias an d are m ore likely to yield an accu rate estim ate o th e tru th (ran dom ized con trolled trials (RCTs)), are re erred to as level-I stu dies ( Ta le ). e el of e idence

Study design

I

Systematic review of homogenous CTs CTwith narrow confidence intervals (high uality)

II

Systematic review of homogenous cohort studies Low- uality CT( 80 follow-up lack of blinding etc) and individual cohort study

III

Systematic review of homogenous case-control studies Individual case-control study

IV

Case series Poor uality cohort study or case-control study

V

Ta le

xpert opinion

Oxford le ve ls of e vide nce

p i n i

Th e ability to assess an d u tilize eviden ce e ectively in decision m akin g is an im portan t skill or ph ysician s. To th is en d, ph ysician s n eed clear recom m en dation s on h ow to iden ti y an d apply th e best available eviden ce to speci c clin ical scen arios. Th is ch apter presen ts a brie description o w h at eviden ce is an d w h y it is n eeded. Th e secon d section w ill in clu de a discu ssion on h ow eviden ce can be in corporated w ith in n on operative ractu re-related scen arios.

im plem en t th e n ew con cepts to h ow to do so sen sibly an d e cien tly, w h ile avoidin g poten tial problem s associated w ith a n u m ber o m iscon ception s abou t w h at EBO is an d w h at it is n ot. Th e EBO-related con cepts o h ierarch y o eviden ce, m eta-an alyses, con den ce in tervals, an d stu dy design h ave becom e so w idespread th at h ealth care providers w illin g to u se an d com preh en d today’s m edical literatu re h ave n o ch oice bu t to becom e am iliar w ith th e prin ciples an d m eth odologies o EBO [3].

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Outcomes after nonoperative fracture treatment—what information can be gained from evidence based medicine

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Outcome s afte r nonoperative fracture tre atment—what information can be gaine d from e vide nce base d me dicine

With an u n derstan din g o th e qu ality an d level o eviden ce, in vestigators an d ph ysician s can apply it to th eir clin ical practice u sin g th e EBM m odel. Eviden ce-based m edicin e w as de n ed in 1996 by Sackett et al as “th e con scien tiou s, explicit, an d ju diciou s u se o cu rren t best eviden ce in m akin g decision s abou t th e care o th e in dividu al patien t” [5]. Th is m odel m ain ly ocu ses on u sin g research eviden ce alon g w ith clin ical expertise in order to m ake decision s based on in dividu alized patien t cases. At th e tim e o its in ception , th e con cept o EBM presen ted a pro ou n d paradigm sh i t in th at, on its ow n , clin ical experien ce w as n o lon ger su cien t. Clin ical experien ce is gain ed by years o w ork as a clin ician , edu cation , an d acqu ired skills [6] bu t n ow , th is n ew paradigm su ggests th at experien ce alon e is in su cien t or m edical decision m akin g. Sackett et al state th at “good doctors u se both in dividu al clin ical expertise an d th e best available extern al eviden ce, an d n eith er alon e is en ou gh ” [5]. Th is paradigm sh i t certain ly paved th e w ay or th e u se o m edical literatu re to e ectively gu ide m edical practice [7, 8].

recom m en dation s w ere m ade u sin g “system atic eviden cebased processes design ed to com bat bias, en h an ce tran sparen cy, an d prom ote reprodu cibility” [14]. Th e stren gth o th ese recom m en dation s is based on th e am ou n t an d type o eviden ce su pportin g th at statem en t. An exam ple: “We su ggest operative xation or ractu res w ith postredu ction radiu s sh orten in g > 3 m m , dorsal tilt > 10°, or in traarticu lar displacem en t or step-o > 2 m m as opposed to cast xation .” Th e stren gth o recom m en dation : m oderate [14].

Eviden ce-based m edicin e n ow requ ires ph ysician s to learn n ew skills in clu din g e cien t literatu re search es an d th e application o orm al ru les o eviden ce in evalu atin g th e clin ical literatu re [7–11]. Yet, even i th e eviden ce is clear, in dividu al situ ation s vary in regard to ben e ts an d risks, th u s, th e n al decision sh ou ld alw ays be in f u en ced by th e valu es, pre eren ces, an d expectation s o both clin ician an d patien t as w ell as th e availability an d costs o th e treatm en t [6, 10].

Non operative ractu re care avoids com plication s th at can poten tially ollow su rgery, eg, in ection , h ardw are irritation o n erve stru ctu res, or so t-tissu e irritation cau sed by prom in en t im plan ts [15]. How ever, redisplacem en t an d m alu n ion are n ot u n com m on a ter n on operative ractu re care [16] (see Ta le ).

For exam ple, con sider th e treatm en t o distal radiu s ractu res. Even th ou gh th ey are th e m ost requ en tly en cou n tered extrem ity ractu re, correct treatm en t is still con troversial an d debated w ith in th e literatu re. A search or th e best available eviden ce produ ces several Coch ran e review s discu ssin g th e m ain th erapeu tic ch oices or distal radiu s ractu res. On e review covers con servative treatm en t an d in clu des 37 ran dom ized an d qu asi-ran dom ized con trolled clin ical trials w ith 4,215 patien ts [12]. Th e in clu ded stu dies w ere o poor qu ality an d h eterogen eou s an d, th ere ore, m eta-an alytic statistics w ere n ot per orm ed. Th e au th ors con clu de th at th ere is in su cien t eviden ce rom ran dom ized con trolled trials to determ in e th e m ost appropriate con servative treatm en t in adu lts [12]. Th e oth er Coch ran e review s or treatm en t o distal radiu s ractu res also on ly sh ow ed in su cien t eviden ce [13]. In a con tin u ed search , ph ysician s w ill com e across a gu idelin e an d eviden ce report by th e Am erican Academ y o Orth opaedic Su rgeon s [14]. Upon takin g a closer look, th is docu m en t on ly in clu des a su m m ary o recom m en dation s speci ically lim ited to acu te distal radiu s ractu res. All

I th e clin ical ou tcom es an d com plication rates o operative versu s n on operative ractu re care are com pared across varyin g ractu re types, accordin g to th e establish ed search strategies o EBM, n ot m an y stu dies are available.

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Possible

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Hardware irritation

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Possible

Possible

Immediate

Late

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arlier

Later

utpatient treatment esources ( In children In adults

etc)

Less ore Less ore

ore Less ore Less

Ta le Com parison of nonope rative and ope rative fracture tre atm e nt—a se le ction

Sin ce all in clu ded stu dies are o h igh qu ality, ie, eviden ce an alogou s to level-I RCTs, th e resu lt in dicates th at n on operative ractu re treatm en t carries less risk o com plication s [14]. Th e operative ractu re treatm en t sh ow s better clin ical ou tcom es, bu t dem on strates an in creased risk o com plication s [14, 17]. Th e di eren ce in clin ical ou tcom e sh ow s n o statistical sign i can ce [17], an d th ere is on ly a tren d w ith 73.7% excellen t an d good resu lts or th e operative treatm en t

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

anson, Klaus Dre sing

5 1.

e fe re n ce s

. Eviden ce-based orth opaed ics: a brie h istor y. Indian J Orthop. 20 08 Apr; 42(2):10 4 –110. 2. Pe t ris o r B, B a n d a ri . Th e h ierarch y o eviden ce: levels o eviden ce an d grades o recom m en dation . Indian J Orthop. 2007 Jan ; 41(1):11–15. 3. e lfe t , a n s o n BP. How to read th e orth opedic literatu re. Am J Orthop. 2005 Sep; 34(9):418 –419. 4. fo rd Ce n t re fo r vid e n ce Ba s e d e d icin e . Levels o Eviden ce. 2009 March . Available rom : h ttp:// w w w. cebm .n et/. [Accessed Au gu st 2009]. 5. Sa c e t t , o s e n e rg , ra , et a l . Eviden ce based m ed icin e: wh at it is an d wh at it isn ’t. BMJ. 1996 Jan 13; 312(7023):71–72. 6. B a n d a ri , o e n s s o n e d s . Clinical Research for Surgeons. New York: Georg Th iem e Verlag; 2009: 20 –27. 7. Co llin s . Eviden ce-based m ed icin e. J Am Coll Radiol. 2007 Au g; 4(8):551–554. 8. vid e n ce Ba s e d e d icin e o r in g ro u p . Eviden ce-based m edicin e. A n ew approach to teach in g th e practice o m ed icin e. JA MA. 1992 Nov 4; 268(17):2420 –2425. 9. i m a n B , o o is t ra B , Pe m e rt o n , e t a l . Can orth oped ic trials ch an ge practice? Acta Orthop. 2010 Feb; 81(1):122–125. oppe

, B a n d a ri

10. Cro ft P, a lm iva a ra , va n Tu ld e r . Th e pros an d con s o eviden ce-based m ed icin e. Spine. 2011 Au g 1; 36(17):E1121–E1125. 11. a n s o n BP, B a n d a ri , u d ig , e t a l . Th e n eed or edu cation in eviden cebased orth oped ics: an in tern ation al su rvey o AO cou rse participan ts. Acta Orthop Scand. 2004 Ju n ; 75(3):328 –333. 12. Pe t ris o r B , B a n d a ri . Prin ciples o teach in g eviden ce-based m ed icin e. Injury. 2006 Apr; 37(4):335 –339. 13. a n d o ll , ad o . Con servative in terven tion s or treatin g distal rad iu s ractu res in adu lts. Coch ran e Database Syst Rev. 2003; (2):CD000314. 14. m e rica n ca d e m o f rt o p a e d ic Su rge o n s . Th e treatm en t o d istal radiu s ractu res. Gu idelin e an d eviden ce report 2009. Available rom : w w w.aaos. org/ research /gu idelin es/dr gu idelin e. pd . [Accessed 2012]. 15. a n s o n BP, re s in g . Operative versu s n on operative treatm en t o ractu res: a system atic an alysis o th e literatu re. Forth com in g 2014. 16. Sa n d e rs , Tie s e r C, Co r e t t B. Operative versu s n on operative treatm en t o u n stable lateral m alleolar ractu res: a ran dom ized m u lticen ter trial. J Orthop Trauma. 2012 Mar; 26(3):129 –134.

17.

ld a

,

re n ga r t . Extern al

xation versu s closed treatm en t o displaced d istal radial ractu res in elderly patien ts: a ran dom ized con trolled tr ial. Current Orthopaedic Practice. 2010; 21(3):288 –295.

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• Wh ile th ere are dem an ds placed on su rgeon s to be am iliar w ith a w ide ran ge o eviden ce-based research , an d to develop th eir ow n skills in literatu re search es, on ly th e h igh est qu ality literatu re en su res in orm ed clin ical practice • Eviden ce-based m edicin e (EBM) ocu ses on u sin g both research eviden ce an d clin ical expertise in order to m ake th e best decision s or patien ts • In dividu al situ ation s can vary, so regardless o th e eviden ce, th e n al decision can be in f u en ced by valu es, patien t an d clin ician expectation s, th e experien ce level o th e su rgeon , an d even costs o treatm en t • In parts o th e w orld w h ere resou rces an d services are lim ited, n on operative ractu re treatm en t is th e m ost com m on , an d can provide good resu lts.

e

Su m m a r

i

Particu larly in th ose parts o th e w orld w h ere resou rces an d m edical services are lim ited, con servative ractu re treatm en t is still th e treatm en t o ch oice. Well train ed su rgeon s an d cast tech n ician s can provide good an d com preh en sive n on operative ractu re treatm en t in th ese region s. Com peten t con servative ractu re care alw ays sh ow s better resu lts com pared w ith in adequ ate operative ractu re treatm en t.

4

n

grou p com pared to 68.1% in th e n on operative grou p [14]. Th e pooled relative risk or com plication s sh ow ed a 23% risk redu ction or com plication s in th e n on operative grou p [14].

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Outcome s afte r nonoperative fracture tre atment—what information can be gaine d from e vide nce base d me dicine

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

IDE INES uidelines for nonoperative treatment and perioperative protection

uidelines

ra ct u re s , d is lo ca t io n s , a n d s u lu a t io n s o f t e u p p e r e t re m it ic a rd d o ls , Cle m e n s u m o n t

5

ra ct u re s , d is lo ca t io n s , a n d s u lu a t io n s o f t e lo e r e t re m it a m i o s e if, u a n a n u e l Co n c a

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No n o p e ra t ive t re a t m e n t o f s p in a l fra ct u re s lo ria n e a rd , Pe t e r ic t e r, Ba s t ia n Sc e id e re r

4

Pe d ia t ric fra ct u re s T o m a s Ne u a u e r

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So ft t is s u e d a m a ge a n d d e fe ct s Cle m e n s u m o n t

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iga m e n t a n d t e n d o n in u rie s a m e l fifi

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Ne r ve in u rie s n d re a rga In d ica t io n s fo r n o n o p e ra t ive t re a t m e n t o f in fe ct io n s a t e Cim e rm a n 3

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osa

ichard Kdols , Cle mens Dumont

ractures, dislocations, and subluxations of the upper extremit ichard Kdols , Cleme ns Dumont

In t ro d u ct io n

ichard Kdols , Cle m e ns Dum ont ichard Kdols

3

u m e ru s Diagnostics Proxim al hum e ral fracture s Indications for nonope rative tre atm e nt—proxim al hum e rus Diaph se al hum e ral fracture s Indications for nonope rative tre atm e nt—diaph sis

ichard Kdols

4

l o a n d fo re a rm Diagnostics Elbow dislocations Ole cranon fracture s adial he ad fracture s ore arm fracture s Indications for nonope rative tre atm e nt

5

ris t Etiolog Diagnostics Indications for nonope rative tre atm e nt hat is fe asible with nonope rative tre atm e nt Nonope rative tre atm e nt of nondisplace d fracture s Nonope rative tre atm e nt of displace d fracture s Close d fracture re duction Contraindications for nonope rative tre atm e nt Postope rative prote ction and afte rtre atm e nt is s and com plications

d

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Cla vicle , s ca p u la , a n d s o u ld e r Diagnostics Clavicle Acrom ioclavicular dislocations Scapula Shoulde r dislocations otator cuff in urie s Indications for nonope rative tre atm e nt Postope rative prote ction of the shoulde r

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ichard Kdols

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Cle m e ns Dum ont

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racture s, dislocations and subluxations of the uppe r e xtremit

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and Carpal fracture s with spe cial re gard to scaphoid fracture s Diagnostics Indications for nonope rative tre atm e nt Acute scaphoid fracture s—what is the e vide nce

6

Cle m e ns Dum ont

e t a ca rp a ls a n d p a la n ge s Cle m e ns Dum ont Diagnostics Indications for nonope rative tre atm e nt—m e tacarpal I thum b Contraindications for nonope rative tre atm e nt—m e tacarpal I thum b Indications for nonope rative tre atm e nt—m e tacarpals II Contraindications for nonope rative tre atm e nt—m e tacarpals II Indications for nonope rative tre atm e nt—phalange s hat is fe asible with nonope rative tre atm e nt Contraindications for nonope rative tre atm e nt—phalange s Postope rative prote ction and afte rtre atm e nt is s and com plications Su m m a r

6

ichard Kdols , Cle m e ns Dum ont

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e fe re n ce s

ichard Kdols , Cle m e ns Dum ont

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u r t e r re a d in g

ichard Kdols , Cle m e ns Dum ont

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Authors

ichard Kdols , Cle mens Dumont

n

ichard Kdols

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Cla vicle , s ca p u la , a n d s o u ld e r

ichard Kdols , Cle m e ns Dum ont

Despite th is, th e kn ow ledge an d skills regardin g n on operative treatm en t are still a prerequ isite or every su rgeon in order to be able to advise th e patien t correctly. Th e air presen tation o an altern ative treatm en t option is cru cial in tim es w h en m edical treatm en t h as to w ith stan d legal review (see topic 6 in ch apter 3 Prin ciples o castin g). Th is ch apter th ere ore explores u pper extrem ity in ju ries an d presen ts e ective n on operative treatm en t option s.

ia gn o s t ics

i

In in ju ries o th e u pper extrem ity, n on operative treatm en t sh ou ld alw ays be con sidered as a possible treatm en t option . Most m etaph yseal an d diaph yseal ractu res, as w ell as in traarticu lar ractu res w ith little to n o displacem en t, an d m ost dislocation s can be treated n on operatively w ith good or at least acceptable resu lts. Yet, as operative treatm en t is steadily im provin g an d th e n eeds an d w ish es o patien ts are m ou n tin g, a lot o n ew operative option s are con stan tly bein g establish ed.

d

e

In t ro d u ct io n

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ractures, dislocations, and subluxations of the upper extremit

Th e ollow in g sequ en ce is recom m en ded: h istory, ph ysical exam in ation , im agin g, an d reevalu ation a ter an alyzin g th e x-rays an d oth er im ages. is t o r

History in clu des review o th e in ju ry (eg, direct or in direct trau m a; h igh or low en ergy), an d o an y con com itan t diseases. P

s ica l e a m in a t io n

Follow th e sequ en ce o in spection , palpation , an d ran ge o m otion . Focu s on : • Wou n ds • Excoriation s • Sore skin be ore per oration • Sw ellin g • Ran ge o m otion (ROM) o elbow , w rist, an d n gers • Sen sory in n ervation • Per u sion . 3 Im a gin g

Stan dardized x-rays sh ou ld be per orm ed in at least tw o plan es: • Clavicle: PA an d axial, both en ds o th e clavicle m u st be seen • AC join t: AP an d AP w ith loadin g com pared w ith th e n on in ju red side • Scapu la: AP an d tan gen tial • Sh ou lder: AP an d axial, an d i n ecessary, ou tlet view (Morrison , Biglian i).

a

b

racture s, dislocations, and subluxations of the uppe r e xtremit

Com pu ted tom ograph y is u sed or th e detailed evalu ation o join t ractu re dislocation s, or or u rth er in orm ation in u n clear x-rays. Magn etic reson an ce im agin g is also h igh ly valu able in sh ou lder join t dislocation s an d rotator-cu in ju ries. e e va lu a t io n

In clu des th e n din gs o h istory, ph ysical exam in ation , im agin g, con com itan t in ju ries, an d evalu ation o th e patien t (age/ pro ession / diseases). Th e treatm en t option s can th en be de n ed an d presen ted to th e patien t.

i

d

e

i

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4

Cla vicle

In diaph yseal ractu res o th e clavicle, n o de n itive recom m en dation can be given on w h eth er operative or n on operative treatm en t is best [1]. Up to n ow , th e m ajority o th ese ractu res h ave been treated n on operatively. Usu ally, a relevan t sh orten in g o th e broken clavicle w ill be treated

ig

Exam ple of a

ig

Clavicle bandage in an adole sce nt

by su rgical xation w ith plates or in tram edu llary n ails in addition to classic in dication s or su rgery, ie, per oration or dan ger o per oration by displaced bon e ragm en ts [2]. In patien ts w ith con com itan t ipsilateral ractu res o th e ribs, operative stable xation o th e clavicle is per orm ed to acilitate ven tilation . For n on operative treatm en t, u se a n eck ) or sh ou lder slin g or pre erably a Gilch rist ban dage ( ig (see ch apter 18.3 Gilch rist ban dage). A clavicle ban dage ( ig ) (see ch apter 18.2 Clavicle ban dage) is an oth er option , h ow ever, th e su rgeon sh ou ld keep in m in d th at du e to th e dan ger o circu latory disorders an d skin in ju ries, problem s can occu r [3]. Non displaced lateral ractu res o th e clavicle are treated n on operatively w ith a Gilch rist ban dage. Displaced ractu res o th e lateral clavicle are seen as an in dication or su rgical treatm en t. How ever, it m u st be poin ted ou t th at in a lon g-term stu dy w ith 15 years o resu lts rom 110 lateral clavicle ractu res treated strictly n on operatively, excellen t resu lts w ere sh ow n [4].

ilchrist bandage

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

In Eu rope, or exam ple, an operative approach is com m on ly avored in active patien ts w ith Rockw ood II an d III in ju ries. Special atten tion is n ecessary or m an u al w orkers, especially w h en h eavy overh ead w ork is to be per orm ed. 4

S o u ld e r d is lo ca t io n s

Dislocation s o th e sh ou lder are in itially redu ced an d treated by a slin g or a Gilch rist ban dage (see ch apter 18.3 Gilch rist ban dage). In you n ger patien ts, th e exten t o th e in ju ry is assessed by m agn etic reson an ce im agin g (MRI). Especially in you n g m en , operative treatm en t is recom m en ded in m ost cases, in accordan ce w ith th e expected ou tcom e. In elderly patien ts, n on operative treatm en t is per orm ed u sin g a Gilch rist ban dage u n til pain ceases (ie, a m axim u m o 4 w eeks). Ph ysioth erapy is stan dard a ter rem oval o th e ban dage.

e n

Most partial ru ptu res o th e rotator-cu can be treated n on operatively. Th e prerequ isite is an accu rate clin ical exam in ation an d evalu ation o th e in ju ry by MRI, w h ich is clear-cu t in com plete ru ptu res bu t less so or partial tears. In ten sive ph ysical th erapy an d regu lar clin ical ch ecku ps are requ ired in order to detect ailu re o th e th erapy early on an d to ch an ge to operative treatm en t i n ecessary. In com plete ru ptu res o th e rotator-cu , operative treatm en t is pre erred depen din g on th e patien t’s dem an ds (w ork, sports, sel -relian ce in th e elderly). In d ica t io n s fo r n o n o p e ra t ive t re a t m e n t

An overview o th e variou s ractu re types or th e clavicle, scapu la, an d sh ou lder, as w ell as th eir treatm en t option s, is presen ted in Ta le .

Sca p u la

Fractu res o th e scapu lar body are treated n on operatively w ith a slin g or Gilch rist ban dage (see ch apter 18.3 Gilch rist ban dage) u n til pain ceases. On ly displaced ractu res o th e glen oid still presen t an in dication or operative recon stru ction . In f oatin g-sh ou lder in ju ries, th e in dication or operative treatm en t depen ds on th e exten t o m edial im paction o th e glen oid ossa an d th e expected loss in ran ge o m otion , u n less an atom ical recon stru ction is per orm ed [5]. 5

o t a t o r cu ff in u rie s

i

Rockw ood grades I-III acrom ioclavicu lar dislocation s (see ch apter 11.1 Ligam en t an d ten don in ju ries) can be treated n on operatively u sin g a sim ple slin g or Gilch rist ban dage (see ch apter 18.3 Gilch rist ban dage) u n til pain ceases. A clavicle ban dage can also be very u se u l (see ch apter 18.2 Clavicle ban dage). Movem en t th erapy is establish ed an d m ost patien ts are able to resu m e th eir w ork an d sports activities a ter 2 to 4 w eeks. In patien ts w ith persistin g pain w ith ou t elevation o th e lateral clavicle, an arth roscopic resection o th e AC join t can be su ccess u l. How ever, i pain persists an d th e lateral clavicle stays elevated, a lateral resection o th e clavicle cou ld be per orm ed.

6

e

cro m io cla vicu la r d is lo ca t io n s

d

3

ichard Kdols , Cle mens Dumont

racture pattern Scapular body

Nonoperati e treatment Slightly displaced

Fractures of the scapular processes

ondisplaced

Fractures of the scapular neck

2 cm medial displacement

Fractures of glenoid rim ( ankart s fracture)

o dislocation

perati e treatment Widely displaced fractures of scapular body Displaced fractures of the coracoid or acromion (take note of an os acromiale) 2 cm medial displacement Instability and dislocation of the glenoid rim

Fractures of the glenoid fossa

Dislocation 2 mm

Dislocation

2 mm

Scapula fractures and ipsilateral clavicle fractures (floating shoulder)

Displacement 5 mm

Displacement 5 mm

Clavicle fractures (diaphyseal)

Displacement without skin and soft-tissue irritation

pen clavicle fractures Imminent skin or pleura perforation Injuries of the neurovascular bundle

Acromioclavicular joint injuries

inor dislocation type ockwood grade I–III

Dislocation of acromioclavicular joint types ockwood grade IV–VI

Lateral clavicle fractures

ondisplaced

Displaced

Clavicle fractures with ipsilateral rib fractures

ot indicated

perative stable fixation of the clavicle

Ta le

Ove rvie w of the fracture t pe s and tre atm e nt options for

the clavicle , scapula, and shoulde r

i

Authors

racture s, dislocations, and subluxations of the uppe r e xtremit

Th e in dividu al steps or ph ysical th erapy o th e sh ou lder are dem on strated in ig 3.

3

u m e ru s

3

ia gn o s t ics

ichard Kdols

For th e h u m eru s, diagn ostics ollow s th e sequ en ce o h istory, ph ysical exam in ation , im agin g, an d reevalu ation a ter an alyzin g th e im ages an d x-rays.

Po s t o p e ra t ive p ro t e ct io n o f t e s o u ld e r

As postoperative protection , a Gilch rist ban dage (see ch apter 18.3 Gilch rist ban dage) can be applied or 4 w eeks ollow in g repair o sh ou lder in stability. An oth er advisable option is th e u se o an abdu ction brace or 6 w eeks ollow in g rotator-cu repair. Neverth eless, ph ysioth erapy sh ou ld start im m ediately a ter su rgery.

3

is t o r

n

e

In clu des review o th e in ju ry (eg, direct or in direct trau m a; h igh or low en ergy), an d con com itan t diseases.

i

3

e d i

3 a e Ph sical the rap afte r a shoulde r in ur a ilchrist bandage se d as passive support Passive ph sical the rap c anging, passive Can include a range of pe ndulum e xe rcise s e g, straight arm m ove m e nt across the che st and to the side , or up and bac be side the bod d anging with we ight Oscillation, cloc wise and anticloc wise e Active ph sical the rap of the shoulde r

c

s ica l e a m in a t io n

Follow th e sequ en ce o in spection , palpation , an d ROM. Focu s on : • Wou n ds • Excoriation s • Sore skin be ore per oration • Sw ellin g • ROM o w rist an d n gers (radial n erve) • Sen sory in n ervation (radial n erve) • Per u sion .

ig

a

P

b

d

e

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

3 Im a gin g

Con du ct x-rays w ith th e ollow in g aspects: • Sh ou lder: AP an d axial • Hu m eru s: PA w ith sh ou lder an d elbow in tw o plan es • Elbow : volo-dorsal an d h u m eru s w ith elbow laterally. Com pu ter tom ograph y (CT) can be u sed or th e detailed evalu ation o join t ractu re dislocation s.

3

Pro im a l u m e ra l fra ct u re s

Most proxim al h u m eral ractu res w ill h eal w ith ou t su rgery. Main ly proxim al h u m eral ractu res th at are n on displaced or on ly m in im ally displaced are in dicated or n on operative treatm en t. Th e th erapeu tic prin ciple is to im m obilize th e u pper arm by secu rin g it to th e ch est u n til th e patien t is largely ree o pain . Th en ph ysical th erapy n eeds to be in itiated, at rst passive an d su bsequ en tly active th erapy an d isom etric stren gth en in g exercises.

Th e ban dage is ch an ged w eekly an d th e ractu re is ch ecked by x-rays. Th e du ration o application sh ou ld be lim ited to 2–3 w eeks. Operative treatm en t is recom m en ded or you n ger patien ts w ith severe ractu re displacem en t. Alth ou gh recon stru ction in patien ts over 55 years o age w ith displaced th ree- ragm en t ractu res is com m on , th ere is n o eviden ce th at operative treatm en t yields better resu lts th an n on operative treatm en t. On th e con trary, it w as dem on strated th at th e com plication rate is sign i can tly h igh er ollow in g su rgery by com parable u n ction al ou tcom e [6–8] (see th e com parative graph at ig 5 ). 3 3

Fractu res o th e proxim al h u m eru s can be treated n on operatively w ith a slin g, a slin g w ith sw ath ( ig 4 a ), a sh ou lder im m obilizer ( ig 4 ), or a Gilch rist ban dage or 3 w eeks ( ig 4 c ) (see ch apter 18.3 Gilch rist ban dage).

In d ica t io n s fo r n o n o p e ra t ive t re a t m e n t— p ro im a l u m e ru s

An overview o th e variou s types o proxim al h u m eral ractu res an d th e option s or treatm en t are presen ted in Ta le .

70

perative

60

onoperative

50 40 30 20

a

b ig

4a c

c

Tre atm e nt of proxim al hum e ral fracture s

a Sling with swath

Shoulde r im m obili e r c

ilchrist bandage

Esse ntiall , the se or sim ilar de vice s provide support for the shoulde r oint

10 0 Fjalestad (12 o)

lerud (24 o)

yto (50 o)

Av

ig 5 The graph shows the ave rage Constant score at follow up prospe ctive , randomi e d studie s on thre e part fracture s using ope n re duction inte rnal xation vs nonope rative tre atm e nt in patie nts e ars

n

Reevalu ation in clu des th e n din gs o h istory, ph ysical exam in ation , im agin g, con com itan t in ju ries, an d evalu ation o th e patien t (age/ pro ession / diseases). Th e treatm en t option s can th en be de n ed an d presen ted to th e patien t.

e

e e va lu a t io n i

4

In addition , a collar an d cu ban dage (see ch apter 18.1 Collar an d cu ban dage) can also be in dicated even th ou gh th e w eigh t o th e arm is n ot su pported sign i can tly. By in terposition o a paddin g roll at th e axilla, bon e align m en t can be in f u en ced w h en tigh ten in g th e ban dage. All ban dages can be w orn ou tside th e patien t’s cloth in g.

e

3

Th e swath is an addition al su pport in order to restrict sh ou lder m otion an d is wrapped arou n d th e h u m eru s an d th e ch est.

d

3

ichard Kdols , Cle mens Dumont

i

Authors

racture s, dislocations, and subluxations of the uppe r e xtremit

/ T classi cation 11 1

Type of fracture

racture pattern

Nonoperati e treatment

perati e treatment

Tuberosity: 11-A1.1

ondisplaced

ecommended treatment

Displaced greater tuberosity fragment: 11-A1.2 and 11-A1.3

ot indicated

ecommended treatment

Impacted metaphyseal: 11-A2.2 varus impacted

Indicated

High angulation – recommended treatment

11

onimpacted metaphyseal: surgical neck Indicated fractures

Possible

With displacement

nly when there are severe underlying diseases

ecommended to avoid impingement

11 B1

Without metaphyseal impaction

nly when there are severe underlying diseases

ecommended to avoid impingement

11 B

With glenohumeral dislocation

nly when there are severe underlying diseases

ecommended treatment

11 B

With glenohumeral dislocation and displacement

nly when there are severe underlying diseases

ecommended treatment

i

d

e

i

n

e

11

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Authors

ichard Kdols , Cle mens Dumont

/ T classi cation

Type of fracture

racture pattern

Nonoperati e treatment

perati e treatment

With slight displacement

ot indicated

ecommended treatment

11

Impacted with marked displacement

ot indicated

ecommended treatment

11

With dislocation

ot indicated

ecommended treatment

i

d

e

i

n

e

11 1

Ove rvie w of proxim al hum e ral fracture t pe s and the ir tre atm e nt options

Ta le

3 4

ia p

s e a l u m e ra l fra ct u re s

Diaph yseal ractu res o th e h u m eru s can be treated n on operatively [9, 10]. Th e treatm en t starts w ith a Desau lt’s ban dage (bin din g th e elbow to th e patien t' s side), a Gilch rist ban dage, or a Velpeau ban dage ( ig 6 ), or a cast, su ch as a U-sh ape splin t ( ig ) or 2 w eeks an d su bsequ en t ch an ge to a Sarm ien to brace (see ch apter 15.5 Sarm ien to h u m eral brace u sin g syn th etic) ( ig ) or an oth er 4–6 w eeks.

ig

6

e lpe au bandage

ig

Patien ts are advised to actively m ove th eir sh ou lder an d elbow w ith in th e brace. Sh orten in g o th e ractu re an d con tact o ragm en ts are prerequ isites or th is treatm en t. Th e ocu s is on th e restoration o axis an d rotation in con trast to th e h u m eru s, w h ich w ill tolerate rotation al m isalign m en t o u p to 30° w ith ou t an y u n ction al de cits.

shape splint

ig

Sarm ie nto hum e ral brace

3

racture s, dislocations, and subluxations of the uppe r e xtremit

In d ica t io n s fo r n o n o p e ra t ive t re a t m e n t— d ia p s is

Lon g, spiral ractu res in th e m iddle o th e diaph ysis are ideally treated n on operatively. How ever, th e m ore tran sverse an d th e m ore proxim al or distal th e ractu re occu rs, th e h igh er th e rate o n on u n ion resu ltin g rom n on operative treatm en t (see Ta le 3 ). A ter application o th e cast, n erve u n ction h as to be reevalu ated in order n ot to overlook secon dary palsy o th e radial n erve du e to com pression betw een th e ragm en ts. In th at case, an absolu te in dication or prom pt operative com pression o th e radial n erve an d stabilization is con stitu ted. Th e rst ch ecku p by x-ray is per orm ed a ter 2 w eeks.

i

d

e

i

n

e

3 5

In elderly patien ts, operative treatm en t is an option in order to preven t pu lm on ary com plication s du e to restriction s o th e th oracic m ech an ics o th e cast.

/ T classi cation 1

1

Type of fracture

racture pattern

Nonoperati e treatment

perati e treatment

Simple spiral

(Applies for all fracture types)

1

bli ue 30° (Applies for all fracture types) Isolated Closed fracture Cooperative patient Alignment nearly anatomical lderly patients

1

4

Transverse 30°

ajor displacement of tuberosities ( 5 mm) shaft fragments ( 20 mm) or head angulation ( 45°) Floating shoulder Floating elbow ilateral fracture of humeral shaft Vascular injury Secondary radial nerve injury Distal humeral fractures Polytrauma patient pen fracture of the humeral shaft Irreducible fracture Severe obesity Patient unable to sit erve interposition between fragments

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Authors

ichard Kdols , Cle mens Dumont

/ T classi cation

Type of fracture

racture pattern

Nonoperati e treatment

perati e treatment

Spiral wedge

1 B1

ending wedge

i

d

e

i

n

e

1 B

Fragmented

1 B

(Applies for all fracture types)

(Applies for all fracture types)

1

Spiral

1

1

Segmental

1

Irregular

Ta le

3

Isolated Closed fracture Cooperative patient Alignment nearly anatomical lderly patients

ajor displacement of tuberosities ( 5 mm) shaft fragments ( 20 mm) or head angulation ( 45°) Floating shoulder Floating elbow ilateral fracture of humeral shaft Vascular injury Secondary radial nerve injury Distal humeral fractures Polytrauma patient pen fracture of the humeral shaft Irreducible fracture Severe obesity Patient unable to sit erve interposition between fragments

Ove rvie w of the various diaph se al hum e ral fracture t pe s and the ir tre atm e nt options

5

racture s, dislocations, and subluxations of the uppe r e xtremit

Follow th e sequ en ce o h istory, ph ysical exam in ation , im agin g, an d reevalu ation a ter an alyzin g th e x-rays an d im ages.

Today, com plex elbow dislocation s are regu larly treated operatively. Neverth eless, as w as sh ow n [11] in selected cases w ith th e “terrible triad”, ie, posterior dislocation o th e elbow join t w ith ractu re o both th e radial h ead an d coron oid process, or even in divergen t dislocation s, n on operative treatm en t can also be su ccess u l.

4

4 3

4

l o

a n d fo re a rm

4

ia gn o s t ics

ichard Kdols

is t o r

i

d

e

i

n

e

In clu des review o th e in ju ry (eg, direct or in direct trau m a; h igh or low en ergy), an d con com itan t diseases. 4

P

s ica l e a m in a t io n

Follow th e sequ en ce: in spection , palpation , an d ROM. Focu s on : • Wou n ds • Excoriation s • Sw ellin g • ROM o w rist an d n gers • Sen sory in n ervation • Per u sion . 4

3 Im a gin g

X-rays sh ou ld be taken as ollow s: • Elbow : volo-dorsal an d radio-u ln ar • Forearm : w ith th e elbow an d th e w rist in tw o plan es. Com pu ted tom ograph y (CT) is u sed or th e detailed evalu ation o join t ractu re dislocation s. 4

4

e e va lu a t io n

In clu des th e n din gs o h istory, ph ysical exam in ation , im agin g, con com itan t in ju ries, an d evalu ation o th e patien t (age/ pro ession / diseases). Th e treatm en t option s can th en be de n ed an d presen ted to th e patien t. 4

l o

d is lo ca t io n s

Sim ple elbow dislocation s are treated n on operatively i closed redu ction is su ccess u l an d n o redislocation occu rs betw een 0-30-90° (n eu tral-0-m eth od). Th ere ore, a correct lateral x-ray h as to be taken a ter redu ction in order n ot to overlook an y su blu xation . Th en th e cast (see ch apter 15.1 Lon g arm splin t u sin g plaster o Paris; an d 15.2 Lon g arm splin t u sin g syn th etic) is applied an d again x-ray review is requ ired. I a circu lar cast is applied, it h as to be split com pletely (see topic 5 in ch apter 3 Prin ciples o castin g; 15.3 Lon g arm cast u sin g plaster o Paris; an d 15.4 Lon g arm cast u sin g plaster o Paris).

le cra n o n fra ct u re s

Olecran on ractu res w ith m in im al displacem en t (< 5 m m ) are treated n on operatively, especially in elderly patien ts. Th e cast is applied in 115° position or 3 w eeks (m odi ed in 115° an gu lation ) (see ch apters 15.1 Lon g arm splin t u sin g plaster o Paris; an d 15.2 Lon g arm splin t u sin g syn th etic). 4 4

a d ia l

e a d fra ct u re s

Radial-h ead ractu res w ith im paction zon e < 30% or displacem en t < 2 m m do n ot n eed operative treatm en t. How ever, a CT scan in order to detect th e am ou n t o displacem en t is recom m en ded. A cotton -w ool ban dage or an elastic ban dage (see ch apter 18.5 Elbow ban dage) is applied or 3–5 days. As an altern ative, a dorsal u pper-arm splin t or cast m ay be u sed (see ch apters 15.1 Lon g arm splin t u sin g plaster o Paris; 15.2 Lon g arm splin t u sin g syn th etic; 15.3 Lon g arm cast u sin g plaster o Paris; an d 15.4 Lon g arm cast u sin g plaster o Paris). 4 5

o re a rm fra ct u re s

Fractu res o th e u ln ar sh a t w ith displacem en t o < 1/ 3 o diam eter can be treated by cast xation [12]. An aboveelbow cast is applied or 2 w eeks (see ch apters 15.1 Lon g arm splin t u sin g plaster o Paris; 15.2 Lon g arm splin t u sin g syn th etic; 15.3 Lon g arm cast u sin g plaster o Paris; an d 15.4 Lon g arm cast u sin g plaster o Paris), an d su bsequ en tly exch an ged or a orearm brace or an oth er 4–6 w eeks (see ch apters 15.11 Sh ort arm cast u sin g plaster o Paris; 15.12 Sh ort arm cast u sin g syn th etic, com bicast tech n iqu e; m odi ed). As an altern ative, u n ction al treatm en t w ith a orearm brace can be ch osen , ie, a m odi cation o th e m eth od described in ch apter 15.20 Sh ort arm cast in clu din g tw o or m ore n gers u sin g syn th etic, com bicast tech n iqu e, h ow ever, w ith ou t in clu din g th e n gers. 4 6

In d ica t io n s fo r n o n o p e ra t ive t re a t m e n t

An overview o th e variou s types o elbow an d orearm ractu res an d th eir treatm en t option s is presen ted in Ta le 4.

In addition to th e circu latory an d n eu rological ch eck on day 1, an oth er x-ray review is m an datory as th e dan ger o redislocation is h igh est on th e rst day. Cast xation is m ain tain ed in pron ation an d 90° f exion or 2–3 w eeks.

6

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Authors

ichard Kdols , Cle mens Dumont

/ T classi cation lbow dislocation

racture pattern Dislocation

Nonoperati e treatment

perati e treatment

Stable after reduction

Complex dislocations of elbow

xtraarticular

Displacement 5 mm

Displacement 5 mm

xtraarticular

Impaction one 30 Displacement 2 mm

Impaction one 30 Displacement 2 mm

i

d

e

i

n

e

lecranon 1 1

Type of fracture

Radial head fracture 1

lecranon head 1

radial

lecranon 1 B1

Radial head fracture 1B

1B

Fractures of radius and ulna

ondisplaced

All others

Articular single bone

Stable nondisplaced or minimally displaced fracture Functional extensor mechanism Very low-demand patient High surgical and anesthetic risk (multimorbidity)

Displaced pen fracture Loss of extensor function

Articular one bone

Fracture 30 of the radial head ondisplaced or displacement 2 mm

Displaced fracture 70 pronation and supination pen fracture Severe soft-tissue injury

Articular one bone and extraarticular at the other bone

ondisplaced

ecommended

racture s, dislocations, and subluxations of the uppe r e xtremit

/ T classi cation

Type of fracture

racture pattern

Nonoperati e treatment

perati e treatment

Simple

xceptional High surgical and anesthetic risk (multimorbidity)

ajority

1

lecranon multifragmentary radial head simple

xceptional High surgical and anesthetic risk (multimorbidity)

ajority

1

Three fragments of each bone

xceptional High surgical and anesthetic risk (multimorbidity)

ajority

Ulna fractured radius intact obli ue ulna

ondisplaced fractures 25 displacement Low-demand compliant patients multimorbidity

pen fracture ultiple trauma Chain injury (ipsilateral fracture) Active patient 25–50 displacement 10–15° malalignment

adius fracture ulna intact obli ue radius

ondisplaced fractures 25 displacement Low-demand compliant patients ultimorbidity

pen fracture Compartment syndrome eurovascular injury elevant soft-tissue injury ultiple trauma Chain injury (ipsilateral fracture) Active patient 25 displacement

i

d

e

i

n

e

1 1

1

Simple fracture both bones

ondisplaced fractures

Golden standard of all displaced forearm fractures

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

ichard Kdols , Cle mens Dumont

B1

Ulna fractured radius intact obli ue ulna

ondisplaced fractures 25 displacement Low-demand compliant patients ultimorbidity

pen fracture Compartment syndrome eurovascular injury elevant soft-tissue injury ultiple trauma Chain injury (ipsilateral fracture) Active patient 25 displacement

B

adius fractured ulna intact

ondisplaced fractures 25 displacement Low-demand compliant patients ultimorbidity

pen fracture Compartment syndrome eurovascular injury elevant soft-tissue injury (Gustilo type I II) ultiple trauma Chain injury (ipsilateral fracture) Active patient 25 displacement 20° malalignment rotation instability

B

ne bone with wedge fracture other simple or wedge

ondisplaced fractures

Golden standard of all displaced forearm fractures

Ulna complex radius simple

are: ondisplaced fracture

Golden standard of all displaced forearm fractures

adius complex ulna simple

are: ondisplaced fracture

Golden standard of all displaced forearm fractures

oth bones complex

are: ondisplaced fracture

Golden standard of all displaced forearm fractures

1

Ta le

4

Ove rvie w of the various t pe s of e lbow and fore arm fracture s and the ir tre atm e nt options

e

perati e treatment

n

Nonoperati e treatment

i

racture pattern

e

Type of fracture

d

/ T classi cation

i

Authors

racture s, dislocations, and subluxations of the uppe r e xtremit

For th e detection o an Essex-Lopresti lesion , th e accu rate ph ysical exam in ation o th e elbow an d th e w rist is cru cial an d gives th e rst track or diagn osis.

5

P

s ica l e a m in a t io n

Ph ysician s sh ou ld ollow th e sequ en ce o in spection , palpation , an d ran ge o m otion , an d look or th e ollow in g in dication s: • Sw ellin g an d w ou n ds • Vascu larity an d capillary per u sion o th e n gers • Location o sore spot (m ost patien ts are able to state precisely w h ere it is located in th e h an d) • Sen sory in n ervation , in particu lar assessm en t o th e m edian n erve • Ho m an n -Tin el sign • Ten don u n ction .

i

d

e

i

n

e

All Mon teggia ractu res (proxim al u ln a ractu res w ith dislocation o th e h ead o th e radiu s), Galeazzi ractu res, an d Essex-Lopresti lesion s are in dication s or operative treatm en t. Th ere ore, in isolated ractu res o th e u ln a, th e ph ysician m u st ocu s atten tion on th e elbow join t n ot to overlook a Mon teggia lesion . Th e sam e is to be m en tion ed w ith isolated ractu res o th e radiu s an d th e distal radiou ln ar join t (Galeazzi).

5 5

ris t

Cle m e ns Dum ont

In regards to distal radiu s ractu res, th ere is m ore th an on e w ay to ach ieve th e objective o u n ction al restoration o th e w rist. Th e requ ired e ort an d ben e t or th e patien t, ie, th e pros an d con s, h ave to be evalu ated in accordan ce w ith th e patien t’s n eeds an d expectation s. Factors su ch as th e patien t’s age, u n ction al dem an ds, an d con com itan t diseases h ave to be taken in to con sideration in order to n d th e best treatm en t option , both in th e sh ort an d in th e lon g term , in con sen su s w ith th e patien t [13]. 5

t io lo g

Regardless o age, gen der, an d osteoporosis, th e ten den cy to all an d th e m an n er o allin g, especially in elderly people, h as an e ect on th e in ciden ce an d ractu re type o th e distal radiu s [14]. Th e an n u al in ciden ce rate o distal radiu s ractu res is abou t 195–290 per 100,000 people, w ith great local varian ce depen din g on th e area observed an d th e age o th e in h abitan ts [15–17]. 5

ia gn o s t ics

Diagn osis is determ in ed by ollow in g th e sequ en ce o h istory, ph ysical exam in ation , x-ray, an d reevalu ation a ter an alyzin g th e x-ray. 5

3 Im a gin g

Th e stan dardized x-ray is per orm ed in tw o plan es an d an alyzed. Evalu ate th e x-ray accordin g to th e clin ical n din gs an d iden ti y th e ractu re pattern . I available, CT scan n in g is a h elp u l tool in veri yin g ractu res an d in assessin g bon y details, eg, exten t o articu lar in volvem en t. A CT scan is th e pre erred m eth od or ju dgin g ractu re pattern s, in traarticu lar in volvem en t, an d in traarticu lar dim en sion o th e ractu re. 5

4

e e va lu a t io n

Clin ical an d diagn ostic n din gs sh ou ld be con gru en t. I th ey are n ot, a secon d clin ical in vestigation is requ ired. I th is alon e does n ot lead to con gru ity o th e n din gs, u rth er radiological diagn ostics are n ecessary. 5 3

In d ica t io n s fo r n o n o p e ra t ive t re a t m e n t

Classi cation o ractu re types is u se u l in stan dardizin g th e treatm en t o veri ed ractu res. Even th ou gh th ere is eviden ce th at reprodu cibility o th ese classi cation s is lim ited [18], an d th at ractu re classi cation accordin g to th e AO/ OTA Fractu re an d Dislocation Classi cation —lon g bon es, does n ot correlate to lon g-term ou tcom es [19], th is classi cation is still w idely u sed in clin ical practice. Criteria describin g ractu re pattern s are h elp u l or su bsequ en t decision m akin g in regard to ractu re progn osis an d ractu re treatm en t option s. An overview o th e variou s types o w rist ractu res an d th eir treatm en t option s is presen ted in Ta le 5.

is t o r

History in clu des review o th e cau se o th e all, i th ere w as direct or in direct trau m a, th e degree o orce, an d con com itan t diseases.

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Authors

ichard Kdols , Cle mens Dumont

/ T classi cation

Type of fracture

racture pattern

Nonoperati e treatment

perati e treatment

xtraarticular fracture of the ulna

Stable radioulnar joint

Irreducible Comminuted fracture Unstable distal radioulnar joint (D U )

xtraarticular fracture of the radius simple/impacted

educible Stable Acceptable/slight secondary displacement

Unstable Secondary displacement

xtraarticular fracture of the radius multifragmentary

educible Stable Serious risk of redisplacement

Irreducible Unacceptable shortening or dorsal inclination Secondary displacement

n

Partial articular B1

Partial articular fracture of the radius sagittal

ondisplaced

Displaced Secondary displacement

B

Partial articular fracture of the radius dorsal ( arton)

ondisplaced

Displaced

B

Partial articular fracture of the radius palmar (reverse arton)

ondisplaced o radiocarpal subluxation

Irreducible Unstable Secondary displacement

Complete articular fracture of the radius Articular simple etaphyseal simple

educible

Irreducible Unstable Secondary displacement

Partial articular 1

Ta le

5

Complete articular fracture of the radius Articular simple etaphyseal multifragmentary

Serious risk of redisplacement

All C2 fractures

Complete articular fracture of the radius Articular multifragmentary etaphyseal multifragmentary

Serious risk of redisplacement

All C3 fractures

Ove rvie w of the various t pe s of wrist fracture s and the ir tre atm e nt options

i

d

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1

e

xtraarticular

racture s, dislocations, and subluxations of the uppe r e xtremit

Listed below are variou s oth er classi cation system s, w h ich w ere developed in th e past an d h ave becom e kn ow n by 6 ). each au th or’s proper n am e ( Ta le racture type

xtraarticular fracture with dorsal dislocation

Cast or operatively

Smith

xtraarticular fracture with palmar dislocation

ostly operatively Cast: Palmar flexion

arton s dorsal

Dorsal articular fragment unstable

ostly operatively

arton s palmar

Palmar articular fragment unstable

ostly operatively

e n

Treatment

Colles

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ocali ation

Chauffeur

adial-styloid fracture

Cast or operatively

Ta le 6 racture t pe and prope r nam e for fracture classi ca tion Note hile the te rm Colle s fracture in the strict se nse is applie d to an e xtraarticular fracture t pe , it is ofte n also use d for dorsall displace d e xtra and intraarticular fracture s

An oth er u se u l classi cation or radiu s ractu res w as establish ed by Melon e [20] ( Ta le ) an d re ers to th e u ln ar aspect o th e articu lar su r ace in particu lar, th e so-called “m edial com plex”. How ever, sin ce th ere still is a lack o ractu re classi cation s providin g 3-D ractu re pattern s based on CT scan s, an d th at also in clu de th e qu ality o bon e stock, th e ollow in g steps w ill h elp ph ysician s in decision m akin g: • Th ey sh ou ld n ote th at in dorsal ractu re dislocation type ractu res, th e Colles’ type predom in ates • Th ey sh ou ld assu m e th at abou t 50% o th e ractu res o th e distal radiu s are in traarticu lar ractu res • Th ey sh ou ld con sider th e age o th e patien t (bon e stock) as an im portan t progn osis actor in regard to th e risk o redisplacem en t • Th ey sh ou ld an alyze th e m edial com plex in case o dou bt w ith th e CT scan . Wh en evalu atin g th e diagn ostic x-rays o radiu s ractu res, tw o qu estion s arise: • Is th e ractu re n on displaced or displaced? Th is can be an sw ered by x-ray or CT scan s • Is th e ractu re stable or u n stable? Th e an sw er to th is qu estion w ill m ore likely be provided by experien ce th an by eviden ce.

5 3

Crit e ria fo r in s t a ilit in d is t a l ra d iu s fra ct u re s

In stability is to be looked or, an d th e direction o in stability – dorsal, radial, u ln a, or palm ar is to be recogn ized. Th e criteria or in stability [21, 22] com prises: • Radial sh orten in g • Radial in clin ation • Palm ar tilt • Dorsal com m in u tion • Fractu re o th e u ln ar styloid • Age o patien t. Ph ysician s sh ou ld be su re to classi y seem in gly “stable” ractu res th at can on ly be redu ced in extrem e position s as “u n stable”, an d assu m e th at th ey h ave to be operated. 5 4

a t is fe a s i le

it

n o n o p e ra t ive t re a t m e n t

Treatm en t goals in clu de restoration o th e radial len gth , th e radial an d palm ar an gu lation , an d th e stepless restoration o th e radiocarpal articu lation . Non operative treatm en t o dom in an t com pared w ith ever, th e risk o residu al n eeds to be balan ced w ith

distal radiu s ractu res is still preoperative treatm en t [23]. How sti n ess du e to im m obilization operation risks.

Du rin g th e period o n on operative treatm en t an d x-ray ch ecku ps, it m u st be veri ed th at n on operative treatm en t w as th e correct decision , or in cases o secon dary redisplacem en t, ch an geover to operative treatm en t h as to be con sidered. 55

No n o p e ra tive tre a tm e n t o f n o n d is p la ce d fra ctu re s

Non displaced distal radiu s ractu res are treated in a sh ort arm plaster o Paris cast or in a sem irigid syn th etic cast or 4–5 w eeks depen din g on th e exten t o th e ractu re an d th e qu ality o th e bon e stock (see ch apters 15.6 Dorsopalm ar (radial) sh ort arm splin t u sin g plaster o Paris; 15.7 Dorsopalm ar (radial) sh ort arm splin t u sin g syn th etic; 15.8 Palm ar sh ort arm splin t u sin g plaster o Paris; 15.9 Palm ar sh ort arm splin t u sin g syn th etic; 15.10 Dorsal sh ort arm splin t u sin g syn th etic; 15.11 Sh ort arm cast u sin g plaster o Paris; an d 15.12 Sh ort arm cast u sin g syn th etic, com bicast tech n iqu e). At rst, in order to avoid com plication s rom sw ellin g, both m aterials h ave to be split com pletely (see topic 5 in ch apter 3 Prin ciples o castin g; an d ch apter 6 Properties o cast m aterials).

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Authors

ichard Kdols , Cle mens Dumont

elone classi cation

racture type

Description ondisplaced or variable displacement of the medial complex stable

Type

Die-punch moderate or severe displacement of the medial complex unstable

i

d

e

i

n

e

Type

Type

Spike fracture displacement of the medial complex as a unit and an additional spike fragment from the radius shaft unstable

Type

Split fracture medial complex severely comminuted wide separation of fragments unstable

xplosion injuries

Type

Ta le

Me lone classi cation of radius fracture s

3

racture s, dislocations, and subluxations of the uppe r e xtremit

5 6

No n o p e ra t ive t re a t m e n t o f d is p la ce d fra ct u re s

In adu lt patien ts, closed redu ction sh ou ld be carried ou t i th e radiu s ractu re is displaced, regardless o bein g stable or u n stable. For exam ple, ig sh ow s th at accordin g to th e degree o displacem en t, eith er n on operative (blu e) or operative (gray) treatm en t is recom m en ded.

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5

Clo s e d fra ct u re re d u ct io n

In adu lt patien ts, closed redu ction is u su ally per orm ed u n der in ltration an esth esia o th e ractu re zon e (ch apter 14.1 Overview o cast, splin t, orth osis, an d ban dage tech n iqu es). For ch ildren , closed redu ction is recom m en ded w ith gen eral an esth esia. Th ere are several w ays to ach ieve closed redu ction depen din g on ractu re displacem en t, im paction , ractu re type, an d bon e qu ality. A ter closed redu ction , plaster o Paris (POP) sh ou ld be u sed in stead o syn th etic.

Closed redu ction o th e ractu re can eith er be per orm ed by m an u al traction or by a lon gitu din al traction device w ith n ger traps ( ig ) (see ch apter 15.15 Sh ort arm cast u sin g plaster o Paris w ith traction an d redu ction ). Lon gitu din al traction by itsel can restore ph ysiological radial len gth , bu t m an u al orce is pre erred, sin ce th is m an eu ver acilitates palm ar tran slation an d u ln ar in clin ation o th e m idcarpu s, i assistan ce is available [14]. Addition al th in gs to con sider: • Avoid per orm in g closed redu ction a secon d tim e, as th e risk o com plex region al pain syn drom e in creases • I th e ractu re is displaced a secon d tim e, operative treatm en t is recom m en ded.

Dista l ra d iu s fra ctu re Nondisplaced

Displaced

Stable

Extraarticular A3

Unstable

Intraarticular B1, C1

Extraarticular A3

Intraarticular B/ C

Closed reduction

Open reduction/ ORIF

Short arm cast/ splint

Additive short arm cast/ splint, orthesis, removable

Reduction maintained

No

Yes Early mobilization, functional aftertreatment

Nonoperative treatment

ig

lue

4

Tre atm e nt algorithm for distal radius fracture s m ostl nonope rative , gra

m ostl ope rative

m odi e d from

,

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

5

Po s t o p e ra t ive p ro t e ct io n a n d a ft e r t re a t m e n t

From th e au th or' s clin ical experien ce, postoperative cast protection , or pre erably, a palm ar syn th etic splin t, is h elpu l even a ter an gle-stable plate osteosyn th esis (see ch apter 15.9 Palm ar sh ort arm splin t u sin g syn th etic). A POP splin t can also be u sed (see ch apter 15.8 Palm ar sh ort arm splin t u sin g plaster o Paris).

e n

Relative con train dication s in clu de: • Un stable or irredu cible ractu res • Fractu re-associated ligam en t in ju ries (radiocarpal or in tercarpal).

Du rin g th e period o im m obilization , th e patien t h as to m obilize th e u n in ju red n ger join ts, th e elbow join t, an d sh ou lder join t as ar as pain allows an d as in stru cted. A tertreatm en t n eeds to be adapted in accordan ce w ith ractu re type, qu ality o bon e, an d th e type o osteosyn th esis.

i

Absolu te con train dication s or n on operative treatm en t in clu de: • Open ractu res • Fractu res w ith severe so t-tissu e trau m a w ith n erve or vascu lar lesion • Com partm en t syn drom e • Perilu n ate dislocation s • Th ese in ju ries sh ou ld be operated im m ediately i perm issible by th e patien t' s con dition .

Patien ts n eed to be in orm ed abou t th e risk o sw ellin g an d in creasin g pain du rin g th e rst h ou rs a ter th e in ju ry. A retu rn visit by th e patien t on th e n ext day is m an datory in order to ch eck so t-tissu e reaction an d cast position ( or m ore detailed in orm ation see topic 11 in ch apter 3 Prin ciples o castin g).

e

Co n t ra in d ica t io n s fo r n o n o p e ra t ive t re a t m e n t

d

5

ichard Kdols , Cle mens Dumont

i

Authors

5

is s a n d co m p lica t io n s

Distal radiu s ractu res can be associated w ith a lesion o th e trian gu lar brocartilage com plex an d carpal ligam en t in ju ries. Du rin g an d a ter redu ction , th e an alysis o th e x-ray an d CT scan sh ou ld especially ocu s on th e position o th e scaph oid, lu n ate, an d u ln a in both plan es an d th e w idth o th e scaph olu n ate distan ce an d in tegrity o Gilu la’s lin es ( ig ). A su blu xation o th e DRUJ can be di cu lt to assess on plain x-rays. I a su blu xation is su spected, CT scan s o both w rist join ts in pron ation an d su pin ation w ill be h elp u l.

Th in gs to con sider: • Recom m en ded am ou n t o tim e or postoperative cast protection w ith daily m obilization o th e n gers ou t o th e splin t/ cast: 2 w eeks or extraarticu lar distal radiu s ractu res an d 4 w eeks or in traarticu lar ractu res • X-ray ch ecku ps are recom m en ded a ter closed redu ction , on days 3, 7, 14, 28, an d 42 • In depen den t exercise su bsequ en t to im m obilization is recom m en ded. Ph ysical th erapy can be added, w h ile occu pation al th erapy h as n ot proved to be su perior a ter su rgical th erapy [25].

a

b

c ig

a c

Exam ple of a distal radius fracture

a X ra on the da of the accide nt

X ra afte r close d re duction ig

inge r trap traction

c X ra afte r

we e s

5

racture s, dislocations, and subluxations of the uppe r e xtremit

6

and

Cle m e ns Dum ont

Th e n al tw o topics in th is ch apter are stru ctu red accordin g to ractu re localization . Begin n in g w ith carpal ractu res, th e ocu s o topic 6 is on th e scaph oid. Th en , topic 7 exam in es m etacarpal an d ph alan geal ractu res.

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6

Ca rp a l fra ct u re s fra ct u re s

it

s p e cia l re ga rd t o s ca p o id

Carpal bon e ractu res are u su ally th e con sequ en ce o allin g on th e h an d. Th e m ost com m on carpal bon e ractu re is th e scaph oid ractu re, w h ich con stitu tes u p to 60% o carpal bon e ractu res [26]. Scaph oid ractu res typically resu lt rom sports or h igh -speed in ju ries in you n ger patien ts. I overlooked, scaph oid ractu res can lead to n on u n ion or avascu lar n ecrosis w ith degen erative ch an ges in th e carpal join ts an d carpal collapse. 6 6

ia gn o s t ics P s ica l e a m in a t io n

ten dern ess du rin g axial com pression alon g th e rst ray or th e th u m b. Neverth eless, pain cau sed by scaph oid ractu res can be m oderate an d on e o th e reason s w h y th is type o ractu re is requ en tly overlooked. 6

Th e stan dardized x-ray im ages in clu de th e ollow in g projection s: dorsopalm ar, lateral, an d Stech er view (dorsopalm ar plan e w ith clen ch ed st an d u ln ardu ction ) ( ig ). In regard to progn osis an d adequ ate ractu re treatm en t, exact ractu re classi cation is n ecessary. For scaph oid ractu re classi cation , CT diagn ostics is n ecessary an d recom m en ded w h en ever available ( ig 3 ). An MRI can also be h elp u l in detectin g a h idden scaph oid ractu re ( ig 4 ). How ever, th e exact ractu re m orph ology is o ten easier to evalu ate in CT scan s. 6 3

Patien ts w ith a scaph oid ractu re u su ally presen t w ith th e eelin g o pain an d ten dern ess. Depen din g on ractu re localization , ten der areas are th e an atom ical sn u box, th e proxim al dorsal scaph oid, th e palm ar scaph oid tu bercle, or

Im a gin g

In d ica t io n s fo r n o n o p e ra t ive t re a t m e n t

Scaph oid ractu res are grou ped in accordan ce w ith th e resu lts o th e CT scan . In th e Herbert or m odi ed Krim m er/ Herbert classi cation , th ey are described as stable (type A) or u n stable (type B) ( Ta le ) [27, 28]. Fractu res o th e scaph oid tu bercle (type A1) are best im m obilized in a splin t (see ch apters 15.13 Th u m b spica splin t u sin g plaster o Paris; an d 15.14 Th u m b spica splin t u sin g syn th etic) or 4 w eeks. Non displaced m iddle an d distal th ird ractu res o th e scaph oid w ith ou t displacem en t can best be treated n on operatively by im m obilization or 6–8 w eeks (see ch apters 15.13 Th u m b spica splin t u sin g plaster o Paris; 15.14 Th u m b spica splin t u sin g syn th etic; an d 15.16 Sh ort arm scaph oid cast u sin g syn th etic, com bicast tech n iqu e).

ig

X ra

Ste che r vie w

6 4

ig 3 A CT scan of an obvious scaphoid fracture in the m iddle third of the sagittal plane

ig 4 An M I of an obvi ous scaphoid fracture in the proxim al third of the sagittal plane

6

cu t e s ca p o id fra ct u re s —

a t is t e e vid e n ce

So ar, n o gen eral regim e exists or acu te n on displaced scaph oid ractu res in th e m iddle th ird (type A2) th at w ou ld con clu sively recom m en d n on operative or operative treatm en t. In a m eta-an alysis an d review o th e literatu re, Bu ijze et al [29] com pared su rgical an d n on operative treatm en t o n on displaced or m in im ally displaced acu te scaph oid ractu res. Bu ijze sh ow ed th at resu lts o u n ction al ou tcom e an d tim e o w ork w ere avorable in th e su rgical grou p (class o eviden ce I II) w h ereas th e com plication rate w as h igh er com pared w ith th e n on operatively treated grou p [29]. Dias observed n o di eren ce in m ediu m -term resu lts in u n ction al or radiological ou tcom e betw een th e operatively treated an d th e n on operatively treated grou p (class o eviden ce I–II) o patien ts w ith acu te scaph oid ractu res [30].

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Authors

ichard Kdols , Cle mens Dumont

Vin n ars et al saw n o lon g-term di eren ces betw een su rgical an d n on operatively treated patien ts [31]. In itial x-rays o th e scaph oid can be w ith ou t n din g. I n o CT scan is available an d typical clin ical sign s o a scaph oid

erbert classi cation

Type of fracture

ractu re persist, a secon d x-ray in Stech er view a ter 1 w eek is recom m en ded. In th e m ean tim e, im m obilization w ith a scaph oid splin t is in dicated (see ch apters 15.13 Th u m b spica splin t u sin g plaster o Paris; an d 15.14 Th u m b spica splin t u sin g syn th etic).

racture pattern

Nonoperati e treatment

perati e treatment

Fracture of the tubercle

Indicated

Possible

ondisplaced fracture in the medial or distal third

Indicated

Can be treated operatively in order to reduce the period of immobili ation

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d

1

e

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n

e

Type A Stable fractures

Type Unstable fractures B1

Long obli ue scaphoid fracture

ot indicated

est treated operatively

B

Displaced or angulated fracture

ot indicated

est treated operatively

B

Fracture of the proximal pole/proximal third

ot indicated

est treated operatively

B

Transscaphoidal fracture as part of a complex perilunate dislocation

ot indicated

est treated operatively

Ta le

e rbe rt classi cation of scaphoid fracture s

,

racture s, dislocations, and subluxations of the uppe r e xtremit

e t a ca rp a ls a n d p a la n ge s

Cle m e ns Dum ont

Metacarpal bon es are in volved in abou t 42–45% o ractu res o th e h an d [32, 33]. Su bcapital ractu res accou n t or m ore th an h al o th e ractu res o th e m etacarpals [33].

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ia gn o s t ics P s ica l e a m in a t io n

Patien ts w ith m etacarpal or ph alan geal ractu res m ost o ten presen t clin ical sign s su ch as sw ellin g, ten dern ess, an d lim ited u n ction . Ph ysician s sh ou ld ch eck or m alrotation , w h ich becom es obviou s in a clen ch ed st, or axial deviation , an d sh orten in g o th e n gers. Th ey sh ou ld also ch eck per u sion an d sen sation sen sitivity in th e n gers. Im a gin g

(AP an d lateral view ) are n ecessary or ph alan geal ractu res an d or su spected m etacarpal ractu res com plem en ted by an addition al x-ray in th e obliqu e plan e. Sh orten in g o th e m etacarpals can be iden ti ed by draw in g a lin e alon g th e m etacarpal h eads III–V. Ch an ges in th e carpom etacarpal join t space can be proven by an “M-lin e” th at n orm ally w ill n ot sh ow in cases o carpom etacarpal su blu xation or lu xation . In d ica t io n s fo r n o n o p e ra t ive t re a t m e n t— m e t a ca rp a l I t u m

gives an overview o th e ractu re pattern s o m etacarpal I as w ell as th e in dication s/ con train dication s or n on operative treatm en t. Ta le

Gen eral x-rays sh ou ld be cen tered on th e area o th e h an d w h ere th e ractu re is su spected. Th e tw o stan dard plan es Type of fracture

racture pattern

Nonoperati e treatment

perati e treatment

xtraarticular fracture of metacarpal I base

Stable (seldom) o palmar angulation o malrotation

Unstable Comminuted fracture Palmar angulation

Intraarticular fracture of the metacarpal I base obli ue

Stable (seldom) Serious risk of redisplacement o malrotation

Unstable Dislocation Secondary displacement

Intraarticular fracture of the metacarpal I base multifragmentary

ondisplaced (extremely seldom) o malrotation

Displaced Secondary displacement

etacarpal I Stable fractures Winterstein

ennett

olando

Ta le

Me tacarpal fracture locali ation and re comm e nde d tre atm e nt

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

ichard Kdols , Cle mens Dumont

4

In d ica t io n s fo r n o n o p e ra t ive t re a t m e n t— m e t a ca rp a ls II

Most m etacarpal ractu res are best treated n on operatively [34]. A n on operative treatm en t regim e is in dicated or n on displaced an d stable ractu res w ith ou t articu lar in volvem en t. Sh a t ractu res o th e m etacarpals III or IV—w ith ou t displacem en t an d su pported by th e in tact m etacarpal ligam en ts o th e n eigh borin g rays—are especially treated n on operatively. Su bcapital ractu res w ith palm ar an gu lation < 20° or m etacarpal II an d III an d < 30° or m etacarpal IV an d V can be treated n on operatively. gives an overview o ractu re pattern s o m etacarpals II–V an d in dication s/ con train dication s or n on operative treatm en t.

With ph alan geal ractu res, splin t or cast im m obilization or 3 w eeks is su cien t in m ost cases (see ch apters 15.17 Dorsopalm ar (u ln ar gu tter) sh ort arm splin t in clu din g tw o or m ore n gers u sin g plaster o Paris; 15.18 Dorsopalm ar (u ln ar gu tter) sh ort arm splin t in clu din g tw o or m ore n gers u sin g syn th etic; 15.19 Palm ar sh ort arm splin t in clu din g th e n gers u sin g plaster o Paris; 15.20 Sh ort arm cast in clu din g tw o or m ore n gers u sin g syn th etic, com bicast tech n iqu e; an d 15.20 Sh ort arm cast in clu din g tw o or m ore n gers u sin g syn th etic, com bicast tech n iqu e). a t is fe a s i le

it

n o n o p e ra t ive t re a t m e n t

Treatm en t goals in clu de restoration o m etacarpal an d ph alan geal len gth , th e an gu lation an d restoration o th e articu lar su r ace w ith ou t a step, an d restoration o n ger an d h an d u n ction .

Ta le

It is sa e to assu m e th at abou t 80% o all ractu res o th e m etacarpals II–V can be treated n on operatively. Non operative treatm en t exam ples are ou n d in th e ollow in g ch apters: 15.17 Dorsopalm ar (u ln ar gu tter) sh ort arm splin t in clu din g tw o or m ore n gers u sin g plaster o Paris; 15.18 Dorsopalm ar (u ln ar gu tter) sh ort arm splin t in clu din g tw o or m ore n gers u sin g syn th etic; 15.19 Palm ar sh ort arm splin t in clu din g th e n gers u sin g plaster o Paris; 15.20 Sh ort arm cast in clu din g tw o or m ore n gers u sin g syn th etic, com bicast tech n iqu e; an d secon darily 15.20 Sh ort arm cast in clu din g tw o or m ore n gers u sin g syn th etic, com bicast tech n iqu e. 5

Co n t ra in d ica t io n s fo r n o n o p e ra t ive t re a t m e n t— m e t a ca rp a ls II

Con train dication s or n on operative treatm en t are rotation al deviation o th e ractu red m etacarpal, con siderable displacem en t, an d sh orten in g o > 2 m m .

Co n t ra in d ica t io n s fo r n o n o p e ra t ive t re a t m e n t— p a la n ge s

Un stable ractu res, displaced ractu res, in traarticu lar ractu res, an d m u lti ragm en tary ractu res are best treated operatively. Po s t o p e ra t ive p ro t e ct io n a n d a ft e r t re a t m e n t

Operatively treated m etacarpal ractu res, depen din g on th e m eth od o reten tion , requ ire postoperative protection (see ch apter 15.23 Metacarpal glove u sin g syn th etic, com bicast tech n iqu e). Postoperative cast protection w ith daily m obilization o th e n gers ou t o th e splin t/ cast is recom m en ded or a period o 2–3 w eeks (see ch apters 15.17 Dorsopalm ar (u ln ar gu tter) sh ort arm splin t in clu din g tw o or m ore n gers u sin g plaster o Paris; 15.18 Dorsopalm ar (u ln ar gu tter) sh ort arm splin t in clu din g tw o or m ore n gers u sin g syn th etic; 15.19 Palm ar sh ort arm splin t in clu din g th e n gers u sin g plaster o Paris; 15.20 Sh ort arm cast in clu din g tw o or m ore n gers u sin g syn th etic, com bicast tech n iqu e; an d 15.23 Metacarpal glove u sin g syn th etic, com bicast tech n iqu e). Early u n ction al th erapy sh ou ld be started as soon as ractu re m orph ology allows.

e

Ph alan geal ractu re localization an d recom m en ded treatm en t is speci ed in Ta le .

n

In traarticu lar ractu res o th e rst m etacarpal (type Ben n ett) an d especially m u lti ragm en tary ractu res (type Rolan do) are m ost o ten displaced. Th ere ore, an operative treatm en t regim e is recom m en ded or th ese types o ractu res.

Ph alan geal an d m etacarpal ractu res th at are stable or stable a ter redu ction , n on displaced or n early n on displaced ractu res, as w ell as extraarticu lar ractu res w ith ou t m alrotation , can all be treated n on operatively.

i

Co n t ra in d ica t io n s fo r n o n o p e ra t ive t re a t m e n t— m e t a ca rp a l I t u m

In d ica t io n s fo r n o n o p e ra t ive t re a t m e n t— p a la n ge s

e

3

6

d

Extraarticu lar ractu res o th e rst m etacarpal (type Win terstein ) w ith ou t displacem en t can be treated n on operatively in a orearm / th u m b splin t or cast or 3–4 w eeks (see ch apters 15.13 Th u m b spica splin t u sin g plaster o Paris; 15.14 Th u m b spica splin t u sin g syn th etic; an d 15.16 Sh ort arm scaph oid cast u sin g syn th etic, com bicast tech n iqu e).

i

Authors

racture s, dislocations, and subluxations of the uppe r e xtremit

Type of fracture

racture pattern

Nonoperati e treatment

perati e treatment

xtraarticular fracture of metacarpal head

Stable Dislocation 30° o malrotation

Unstable Comminuted fracture Dislocation 30°

Intraarticular fracture of the metacarpal head

Stable Acceptable/slight secondary displacement

Unstable Secondary displacement

xtraarticular fracture of the metacarpal diaphysis obli ue

educible Stable Serious risk of redisplacement

Irreducible Unacceptable shortening or palmar inclination Secondary displacement

xtraarticular fracture of the metacarpal diaphysis multifragmentary

educible Stable Serious risk of redisplacement

Irreducible Unacceptable shortening or dorsal inclination Secondary displacement

etacarpal

i

d

e

i

n

e

Head

Shaft

ase Intraarticular fracture of the metacarpal base

Ta le

3

ondisplaced

Displaced Secondary displacement

Me tacarpal fracture locali ation and re comm e nde d tre atm e nt

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Authors

ichard Kdols , Cle mens Dumont

Type of fracture

racture pattern

Nonoperati e treatment

perati e treatment

Articular fracture of the phalanx obli ue unicondylar

Stable

Irreducible Comminuted fracture Unstable D U

Articular fracture of the phalanx bicondylar

educible Stable Acceptable/slight secondary displacement

Unstable Secondary displacement

xtraarticular fracture of the phalanx transvers

educible Stable Serious risk of redisplacement

Irreducible Unacceptable shortening or palmar inclination Secondary displacement

xtraarticular fracture of the phalanx multifragmentary

educible Stable Serious risk of redisplacement

Irreducible Unacceptable shortening or dorsal inclination Secondary displacement

Phalanx

i

d

e

i

n

e

Head

Shaft

ase Articular fracture of the phalanx obli ue unicondylar

ondisplaced

Displaced Secondary displacement

ase of the distal phalanx Articular fracture of the distal phalanx

Ta le

educible Stable Fragment 30 of the articular surface

Subluxation Unstable Gross dislocation

Phalange al fracture locali ation and re com m e nde d tre atm e nt

3

racture s, dislocations, and subluxations of the uppe r e xtremit

is s a n d co m p lica t io n s

Su m m a r

i

d

e

i

n

e

Prolon ged im m obilization can lead to u n ction al im pairm en t. Th e proxim al in terph alan geal join t is especially at risk. Im m obilization o u n in ju red n gers can also lead to u n ction al de cits. Malrotation o m etacarpal ractu res is a requ en t risk an d clin ical in vestigation dem an ds payin g special atten tion . Fu rth erm ore, in m etacarpal an d ph alan geal ractu res, th e gen eral risks w ith bon e h ealin g, eg, n on u n ion exist.

3

ichard Kdols , Cle m e ns Dum ont

• Fractu res an d dislocation s in th e u pper extrem ity can be su ccess u lly treated n on operatively, particu larly i th ere is little to n o ractu re ragm en t displacem en t • Fractu res o th e clavicle an d scapu la, an d acrom ioclavicu lar an d sh ou lder dislocation s, are in itially treated w ith a slin g or Gilch rist ban dage, bu t ractu res o th e glen oid ossa, or an y dan ger o per oration by displaced bon e ragm en ts, are typically in dication s or operative treatm en t • Most proxim al h u m eral ractu res, particu larly i m in im ally or n on displaced, w ill h eal w ith ou t su rgery, an d are im m obilized by secu rin g th e u pper arm to th e ch est u n til th e patien t is largely ree o pain • Diaph yseal ractu res o th e h u m eru s can be treated n on operatively w ith a Desau lt' s, Velpeau , or Gilch rist ban dage or cast or 2 w eeks an d su bsequ en t ch an ge to a Sarm ien to brace • Sim ple elbow dislocation s can be treated n on operatively alth ou gh com plex elbow dislocation s are regu larly treated operatively • Radial h ead ractu res an d orearm ractu res w ith on ly sligh t displacem en t can both be treated w ith cast xation • Proxim al u ln a ractu res w ith dislocation o th e h ead o th e radiu s, or isolated ractu res o th e radiu s w ith dislocation at th e distal radiou ln ar join t are both in dication s or operative treatm en t • In th e w rist, n on operative treatm en t o distal radiu s ractu res is m ore com m on , yet ph ysician s m u st con sider an y risk o residu al sti n ess du e to im m obilization , an d en su re th e stability o th e ractu res/ join ts • In th e h an d, scaph oid ractu res can lead to n on u n ion , avascu lar n ecrosis, an d even carpal collapse, so ractu res o th e scaph oid bon es sh ou ld typically be treated n on operatively on ly i th ey are classi ed as stable • Ph alan geal an d m etacarpal ractu res th at are stable or n on displaced, as w ell as extraarticu lar ractu res w ith ou t m alrotation , can all be treated n on operatively.

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

ichard Kdols , Cle mens Dumont

e fe re n ce s

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asn

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12.

i

e n s u rg , T t e rle ig

e

, an

d

1. C e u n g

ichard Kdols , Cle m e ns Dum ont

i

Authors

33

racture s, dislocations, and subluxations of the uppe r e xtremit

u r t e r re a d in g Su rge r

ichard Kdols , Cle m e ns Dum ont

e fe re n ce Castin g. Colton CL,

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, P e S , Co c e rill

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,

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in d o lf , u e ge r

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Klaviku lasch a t raktu r – Klassi kation u n d Th erapie. [M idsh a t clavicle ractu res—Classi cation an d th erapy. Resu lts o a su r vey at Germ an trau m a departm en ts]. Un allchirurg. 2008 Ju n ; 111(6):387–394. Germ an .

, Sa n d s t r m B, e t a l

Non operative treatm en t o prim ar y an terior sh ou lder dislocation in patien ts orty years o age an d you n ger: a prospective twen ty- ve year ollow-u p. J Bone Joint Surg Am. 2008 May; 90(5):945 – 952.

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it t ic

a r u io P, Tro p e t , e t a l

[ Fu n ction al treatm en t o isolated ractu res o th e u ln ar sh a t in adu lts. A prospective stu dy apropos o ten cases an d review o th e literatu re]. Ann Chir Main Memb Super. 1997; 16(3):252 –257. Fren ch .

o ve liu s ,

,

, Sla a u g P, e t a l

Treatm en t o u ln ar sh a t ractu res: A prospective, ran dom ized stu dy. Orthopedics. 1995 Ju n ; 18(6):543 –547. Bis o p

Konservative Methoden in der Frakturbehandlung. [Conservative methods in bone racture treatment]. 1st ed. Wien , Mü n ch en , Baltim ore: Urban & Sch warzen berg;1985. Germ an . a na

Divergen t d islocation o th e elbow treated w ith a cast brace: case report. Eur J Orthop Surg Traumatol. 2006; 16:360 –361.

Pra s a s

, a fe e

, C o u gle

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

ami Moshe iff, uan Manue l Concha

ractures, dislocations, and subluxations of the lower extremit ami Moshe iff, uan Manue l Concha

am i Moshe iff, uan Manue l Concha

3

ia gn o s t ics

am i Moshe iff, uan Manue l Concha

3

am i Moshe iff

3

4

ia p s e a l a n d d is t a l fe m u r Indications for nonope rative tre atm e nt Nonope rative tre atm e nt

am i Moshe iff

4

5

ia p s e a l t i ia Indications for nonope rative tre atm e nt Nonope rative tre atm e nt

am i Moshe iff

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6

is t a l t i ia Indications for nonope rative tre atm e nt Nonope rative tre atm e nt

am i Moshe iff

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oot indfoot Midfoot ore foot m e tatarsals, phalange s Su m m a r

i

Pro im a l fe m u r Indications for nonope rative tre atm e nt Nonope rative tre atm e nt

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In t ro d u ct io n

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Authors

uan Manue l Concha

4

am i Moshe iff, uan Manue l Concha

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e fe re n ce s

am i Moshe iff, uan Manue l Concha

5

u r t e r re a d in g

am i Moshe iff, uan Manue l Concha

5

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Authors

ami Moshe iff, uan Manue l Concha

n

am i Moshe iff, uan Manue l Concha

i

ia gn o s t ics

am i Moshe iff, uan Manue l Concha

Th e precise iden ti cation o th e skeletal in ju ry an d diagn osis o th e ractu re type are per orm ed in th e sam e m an n er as w ith a com m on su rgical treatm en t o ractu res o th e low er extrem ities. Im ages are u sed, rom th e ou tset, as th e basis or th e iden ti cation o th e in ju ry (it sh ou ld be n oted th at th e im ages sh ou ld in clu de th e en tire a ected bon e as w ell as its adjacen t join ts, both proxim ally an d distally). I th ere is a dou bt as to th e presen ce o an in traarticu lar in ju ry, or i th ere is a n eed o a m ore precise u n derstan din g o th e in ju ry, m ore soph isticated m eth ods are u sed, su ch as CT.

In th e oot, or exam ple, in ju ries are com m on . Som e o th em are very obviou s bu t oth ers are di cu lt to diagn ose an d m u st h ave a h igh in dex o clin ical su spicion as th ey can go u n n oticed. Som e oot in ju ries can be treated orth opedically, yet oth ers m u st be im m obilized w h ile th e con dition o th e so t tissu e im proves an d th e xation is per orm ed.

In th e oot, th e de orm ity an d pain in dicate th e in ju red area an d accordin gly, diagn ostic aid sh ou ld be requ ested. X-rays are th e m ain stay o th e im ages, h ow ever, takin g in to accou n t th e overlappin g bon e an d oot tri-dim en sion al settin gs, CT an d th ree-dim en sion al im ages can be h elp u l to better u n derstan d th e variou s in ju ries. Exception ally, MRI is requ ired in th e acu te stage.

Yet, regardless o ractu re location an d severity, am iliarity w ith n on operative treatm en t is essen tial, an d takin g particu lar care o proper redu ction , xation , an d m obility, accordin g to th e patien t' s con dition , is critical or th e su ccess u l treatm en t o ractu res o th e low er extrem ities.

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Pro im a l fe m u r

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Most u n stable or in traarticu lar ractu res w ith m ovem en t con stitu te an in dication or su rgical treatm en t. Th is kin d o treatm en t allow s or an atom ical redu ction , stable xation , an d early m obilization . Bu t despite th e progress in m edicin e an d tech n ology, th ere are still patien ts or m edical situ ation s th at n ecessitate n on operative treatm en t. Th is kin d o treatm en t is com plex, especially in ractu res o th e low er extrem ity, or it deprives th e patien t o m obility or a lon g period o tim e, an d th e n ecessary com prom ises can cau se perm an en t disability in th e u tu re.

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In t ro d u ct io n

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am i Moshe iff

Fractu res o th e h ip still presen t a m ajor cau se o m orbidity an d m ortality all over th e w orld. A sign i can t n u m ber o patien ts th at h ave su stain ed h ip ractu res w ill die w ith in on e year. From th e socioecon om ic poin t o view , th e econ om ic cost to am ilies, patien ts, an d society is su bstan tial. Most ractu res pertain in g to th e em oral n eck an d in tertroch an teric region occu r in elderly patien ts du e to osteoporotic bon e an d/ or m u scu lar in coordin ation leadin g to a all. I a you n g patien t su ers su ch a ractu re, it is o ten th e resu lt o sign i can t trau m a an d is associated w ith u rth er ractu res an d in ju ries.

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racture s, dislocations, and subluxations of the lower e xtre mit

In d ica t io n s fo r n o n o p e ra t ive t re a t m e n t

It is n ow u n iversally agreed th at in tertroch an teric or pertroch an teric ractu res o th e em u r are best treated by operative in tern al xation , w h en ever th is is easible. Wh en ever th e risks o su rgery an d an esth esia are too great, it m ay n ot be advisable to operate th e patien t. Th e “predictors o m ortality” as classi ed by th e Am erican Society o An esth esiologists (ASA) in dicate th e level o risk [1]. In th e case o an in tracapsu lar ractu re, w h ich requ ires h em iarth roplasty, th ere is an addition al risk o dislocation , an d th e u ll cooperation o th e patien t is vital. I th e patien t is sen ile an d su ers rom dem en tia, an d is th ere ore n ot able to cooperate, n on operative treatm en t w ou ld be in dicated.

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n en ce, an d th e n on operative treatm en t o th ese ractu res presen ts orm idable n u rsin g di cu lties. Non operative treatm en t o h ip ractu res sh ou ld alw ays be con sidered an option , an d it is th ere ore n ecessary to decide w h ich tech n ical prerequ isites are o im portan ce, both in regard to th e com ort o th e patien t an d th e con ven ien ce o th e n u rsin g sta . Balan ced traction (a su spen sion system th at su pports traction in th e treatm en t o low er-extrem ity ractu res) is o ten th e best orm o n on operative treatm en t becau se treatm en t by a plaster h ip spica is n ot appropriate in old an d sen ile patien ts. Ta le provides an overview o th e variou s types o proxim al em u r ractu res an d th e available treatm en t option s.

No n o p e ra t ive t re a t m e n t

I su ch ractu res occu r in elderly patien ts, th eir gen eral m edical con dition sh ou ld be assessed, especially sin ce th ese patien ts are o ten su erin g rom deh ydration . Th e su rgeon m u st also look ou t or oth er m edical con dition s, ie, a stroke an d/ or oth er h yperten sive episodes as w ell as cardiac con dition s. Th e n u rsin g requ irem en ts sh ou ld also be evalu ated becau se m an y o th ese patien ts are in an advan ced state o sen ility, som etim es com plicated by dem en tia an d in con ti-

/ T classi cation

Type of fracture

racture pattern

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Tra ct io n s e le t a l ve rs u s a d e s ive

In order to gu aran tee good resu lts in a m an n er m ost com ortable to th e patien t an d m ost con ven ien t or th e n u rsin g sta , skeletal traction (w h ere a pin or w ire is su rgically in serted in to bon e) is applied to th e tibial tu bercle. Th is is recom m en ded over skin adh esive traction (u sin g adh esive straps on th e skin ).

Nonoperati e treatment

perati e treatment

1

3

1 1

Simple pertrochanteric

arely ed-ridden debilitated patients Severe soft-tissue problems in surgical area

Standard treatment

1

Pertrochanteric multifragmentary

arely ed-ridden debilitated patients Severe soft-tissue problems in surgical area

Standard treatment

1

Intertrochanteric

arely ed-ridden debilitated patients Severe soft-tissue problems in surgical area

Standard treatment

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Authors

ami Moshe iff, uan Manue l Concha

/ T classi cation

Type of fracture

racture pattern

Nonoperati e treatment

perati e treatment

onambulatory patients

ecommended treatment

1B

Subcapital with slight displacement

1B

Transcervical

Severe soft-tissue problems in surgical area Patients willing and able to risk fracture displacement xtremely high-risk patients isk of secondary displacement up to 50

ecommended treatment

1B

Subcapital displaced nonimpacted

Severe soft-tissue problems in surgical area Patients willing and able to risk fracture displacement xtremely high-risk patients isk of secondary displacement up to 50

ecommended treatment

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Split (Pipkin)

1

With depression

inor depression fractures Significant comorbidity

1

With neck fracture

Used rarely

Ta le

nly after complete reduction

ecommended treatment

ecommended treatment for (large) depressed fractures

ecommended treatment

Ove rvie w of the various t pe s of proxim al fe m ur fracture s and the available tre atm e nt options

3

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Adh esive traction sh ou ld n ever be com bin ed w ith w eigh t traction . A com bin ation o w eigh t traction w ith skin adh esive traction w ill alm ost in evitably resu lt in th e “creepin g” o th e adh esive strappin g. As a resu lt, pressu re sores m ay appear, w ith excoriation o th e skin an d con com itan t pain . Extern al popliteal paralysis is also a requ en t resu lt o adh esive traction becau se, as th e adh esive ban dages slide dow n th e leg over tim e, th e su rrou n din g circu lar tu rn s o cotton ban dage m ay con strict th e lim b as th ey pass rom th e sm all circu m eren ce o th e kn ee to th e larger circu m eren ce at th e h ead o th e bu la. Especially in elderly patien ts, th e decision on w h ich m eth od to u se sh ou ld be in avor o skeletal traction despite th e act th at m an y ph ysician s are w ary o th is tech n iqu e, it bein g an in vasive procedu re.

4

A Stein m an n pin can easily be in serted u n der local an esth esia, relievin g th e patien t' s discom ort. It is recom m en ded to apply a below -kn ee plaster cast, over adequ ate paddin g, an d to in corporate th e Stein m an n pin in th e u pper en d o th e plaster. Havin g com pleted th e traction u n it, it can be su spen ded rom a Balkan beam an d a 3 kg traction w eigh t, arran ged to give a h orizon tal pu ll by m ean s o cords an d pu lleys ( ig ).

Fractu res o th e distal em u r m ay be extraarticu lar or in clu de an in traarticu lar com pon en t. Mism an agem en t o an y o th ese ractu res can resu lt in abn orm alities o align m en t o th e load bearin g axis o th e low er lim b an d/ or rotation al de orm ities. Th ese can h ave pro ou n d biom ech an ical con sequ en ces. In addition , in traarticu lar ractu res can resu lt in join t irregu larities, leadin g to degen erative join t disease.

s e a l a n d d is t a l fe m u r

am i Moshe iff

Th e in ciden ce o distal em oral ractu res h as been ou n d to be ten tim es less requ en t th an o proxim al em oral ractu res [2]. Du rin g th e period o 1980–1989, approxim ately 34,000 em oral ractu res w ere reported in Eu rope or exam ple, an d on ly 6% (2,165) o th ese in volved th e distal em u r. Distal em oral ractu res can resu lt rom eith er h igh -en ergy or low en ergy trau m a. High -en ergy trau m a, rom m otor veh icle acciden ts, sports, or pedestrian acciden ts, occu r m ore o ten in m en betw een th e ages o 15–50, w h ereas low -en ergy trau m a, su ch as alls rom stan din g h eigh t at h om e, are m ore likely to lead to distal em oral ractu res in elderly people [2].

4

Th e Ham ilton Ru ssell traction or treatin g h ip ractu res can do w ith ou t th e com plicated system o pu lleys, w h ich are n eeded or th e treatm en t o sh a t ractu res. How ever, su spen sion o th e low er extrem ity an d application o traction alon g th e axis o th e em u r are requ ired. Hip cases do n ot call or both orces to be correlated becau se th ere is n o n eed or an u pw ard li t w h ich , in sh a t ractu res, is n eeded in order to correct th e backw ard an gu lation .

ia p

In d ica t io n s fo r n o n o p e ra t ive t re a t m e n t

Non operative treatm en t sh ou ld on ly be resorted to as a tem porary m easu re. Non operative treatm en t is reserved or exception al cases, ie, i th e gen eral m edical con dition does n ot allow sa e an esth esia. I n on operative treatm en t is ch osen , extern al xation is recom m en ded. Skeletal or adh esive skin traction m ay be u sed as an altern ative sh ort-term treatm en t, in order to m in im ize lim b sh orten in g an d to provide som e pain relie . provides an overview o th e variou s ractu re types o th e distal em u r an d th e available treatm en t option s. Ta le

4

No n o p e ra t ive t re a t m e n t

Option s or n on operative treatm en t or th ese types o ractu res o th e em u r typically in clu de: • Traction • Fractu re braces.

Pin insertion sites on the limb

3 kg ody weight

ig S e le tal traction with the lowe r lim b in a be low ne e cast incorporating Ste inm an pins e xte nsion The dire ction of the traction force s is indicate d b arrows

4

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Authors

ami Moshe iff, uan Manue l Concha

/ T classi cation

racture pattern

Nonoperati e treatment

perati e treatment

Simple fractures

arely

ecommended treatment

Wedge fractures

arely

ecommended treatment

Complex fractures

arely

ecommended treatment

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xtraarticular

B

Ta le

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ondisplaced no additional knee ligament injury

ecommended treatment

Partial articular

arely

ecommended treatment

Complete articular

arely

ecommended treatment

Ove rvie w of the various fracture t pe s of the distal fe m ur and the available tre atm e nt options

Tra ct io n

In ractu res o th e m iddle th ird o th e em u r, th e m eth od devised by Th om as (ie, th e Th om as splin t) is u n su itable becau se o th e di cu lty o con trollin g th e proxim al ragm en t. On th e oth er h an d, or ractu res in th e low er th ird o th e em u r sh a t, n on operative treatm en t u sin g th e Th om as splin t is su perior to all oth er n on operative m eth ods.

Thom as splint

Th e Th om as splin t acts as a cradle. Th ere is n o xed lin k to th e skeleton an d, th ere ore, n o in f u en ce on con trollin g th e de orm ity ( ig ).

Th e Th om as splin t com bin es xed traction w ith cou n ter traction applied to th e rin g in th e splin t, an d di ers com pletely rom all oth er con servative m eth ods u sin g com bin ation s o w eigh t traction w ith cou n ter traction exerted by body w eigh t. Th e m eth ods u sin g w eigh t traction , su bsu m ed u n der th e term "traction -su spen sion m eth ods", are n u m erou s, bu t essen tially th e splin t takes secon d place to th e action o th e traction orce, an d in deed, in som e cases, n o splin t is u sed at all. Th e prin cipal m eth ods o u sin g w eigh t traction are described below .

ig

Thom as splint The splint acts as a cradle

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racture s, dislocations, and subluxations of the lower e xtre mit

Traction b

raun fram e

Pe r ins traction

In th is m eth od, th e splin t also serves as a cradle or th e lim b. Moreover, th e position o th e pu lleys can n ot be altered, an d th e size o th e splin t o ten does n ot t th e lim b exactly, an addition al disadvan tage. Lateral bow in g o ten occu rs becau se th e splin t an d th e distal ragm en t are xed to th e ram e, w h ereas th e patien t an d proxim al ragm en t can m ove aw ay rom th e ram e ( ig 3 ).

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am ilton usse ll traction

Th e m ost gen erally u sed type o traction is kn ow n as Ham ilton Ru ssell traction or sim ply Ru ssell traction . Posterior an gu lation o th e distal ragm en t is con trolled by a slin g; th e li tin g orce o th is slin g is lin ked to th e m ain traction orce th rou gh th e pu lleys. No rigid castin g is u sed in th is m eth od. Ham ilton Ru ssell devised th is system or th e treatm en t o ractu res o th e em oral sh a t. He developed a com plicated system o pu lleys in order to correlate th e traction orce n ecessary to m ain tain len gth w ith th e u pw ard li tin g orce n ecessary to correct backw ard an gu lation at th e ractu re site. Th is is accom plish ed by su pportin g th e ractu red lim b in a slin g u n der th e distal th ird o th e th igh , an d u sin g a traction orce attach ed to th e slin g in order to give an u pw ard li t by an arran gem en t o pu lleys. Th e sam e cord th at exerts th e traction orce passes th rou gh pu lleys, w h ich dou ble its pu ll alon g th e len gth o th e tibia below th e kn ee. By estim atin g th e direction o th e traction orce actin g on th e slin g, a parallelogram o orces actin g in th e axis o th e em u r m ay be calcu lated ( ig 4 ).

a

is traction

Fisk traction is a variation o th e Th om as splin t, an d is arran ged to allow 90° o kn ee m ovem en t. It is particu larly u se u l becau se it allow s th e active exten sion o th e kn ee join t. Fixation an d align m en t en tirely depen d on w eigh t traction ; th e splin t tran s ers th e m otive pow er or assisted kn ee m ovem en ts. 4

ra ct u re

ra ce s

in ge d

nee

ra ce

Th e h igh su ccess rate resu ltin g rom th e am bu latory treatm en t o patien ts w ith a ractu red tibia led to a w idely accepted sim ilar approach in th e treatm en t o ractu res o th e em u r. Th e rate o u n ion h as been sh ow n to be h igh . In on e report, 150 patien ts in ractu re braces h ad a m ean treatm en t tim e o 14.5 w eeks an d n o n on u n ion . Du rin g th e sam e period, a ran dom ized grou p o 50 patien ts treated in spica casts h ad a m ean treatm en t tim e o 24.7 w eeks w ith 6 cases o n on u n ion [3]. Th e lon gitu din al m ovem en t o th e em oral ragm en ts w h en treated w ith th e ractu re brace w as stu died by Con n olly an d Kin g [4]. Th ey ou n d th at th e am ou n t o tran slator m otion w as related to th e ractu re type rath er th an to th e w eigh t bearin g on th e lim b. In gen eral, th e tran sverse m idsh a t ractu re m oved m ost, w ith an average m ovem en t o 1.2 cm .

b

ig 3a raun fram e The patie nt and proximal fragm e nt a can m ove awa from the fram e to allow re duction

4

Th is m eth od does n ot u se casts/ splin ts. Th e posterior an gu lation o th e th igh is con trolled by a pillow ; align m en t an d xation com pletely depen d on th e action o con tin u ou s traction .

ig 4 am ilton usse ll traction The arrows point out the paral le logram of force s

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

ami Moshe iff, uan Manue l Concha

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Polycen tric h in ges allow sligh tly m ore m argin or error th an sin gle-axis h in ges. Th e h in ges sh ou ld be parallel an d on th e sam e join t lin e (m odi cation o th e m eth od described in ch apter 16.4 Hin ged kn ee brace w ith a lon ger proxim al part/ sleeve). Th e m ajor reason or in clu din g th e oot in th e cast is to provide su spen sion . A pelvic belt is an oth er possible m ean s o su spen sion i th e oot is n ot in corporated w ith in th e cast, or in obese patien ts.

e

In applyin g th e cast, th e area o th e th igh is th e m ost critical or an exact t. To en su re total con tact, an elastic stu m p sock (w ell- ttin g tu be ban dage) is applied an d covered w ith on e layer o cast paddin g. Th e patella an d join t lin e are m arked on th e layer o cast paddin g in order to provide su bsequ en t positive iden ti cation o th e join t lin e. Th e in itial rolls o plaster sh ou ld be elastic, ollow ed by stan dard ast-dryin g plaster rolls. Th e m oldin g o th e th igh sh ou ld con orm to th e accepted prin ciples or above-kn ee sockets. Th ere sh ou ld be com pression w ith a f at lateral w all or side bearin g. Com pression sh ou ld also be applied over th e em oral trian gle in order to en su re an an teroposterior t i n o qu adrilateral socket is u sed. Th e su pracon dylar area sh ou ld be m olded m edially in order to ach ieve better com pression an d som e su spen sion , an d to im prove con tact w ith th e lateral w all.

A below -kn ee cast is th en applied in th e u su al m an n er. Th e kn ee join t sh ou ld be position ed as close to th e an atom ic axis as possible. Th is sh ou ld be abou t th e m idpoin t o th e patella an d 2 cm beh in d th e m idlin e.

d

Th e ragm en ts did n ot rem ain in sh orten ed position bu t retu rn ed to th eir origin al position du rin g th e sw in g ph ase. Th e treatm en t begin s w ith skeletal traction , applyin g th e u su al tech n iqu es in order to obtain correct align m en t an d rotation . Th e optim al tim e or applyin g th e ractu re brace h as yet to be stan dardized. Som e ph ysician s recom m en d its application a ter on ly 1 w eek o traction , w h ile oth ers w ait u n til th e ractu re site is n o lon ger ten der an d n o sh orten in g occu rs w h en traction is rem oved. A period o 3–4 w eeks is accepted practice, leavin g th e tran sverse m idsh a t ractu re in traction a little lon ger.

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Th e m ost com m on di cu lty en cou n tered is edem a o th e kn ee, w h ich is n ot covered by th e cast. Usu ally, th is situ ation is on ly an n oyin g, bu t occasion ally it m ay be so severe as to lim it am bu lation . Man agem en t is sym ptom atic w ith an elastic ban dage, elevation , an d am bu latin g, w ith th e h in ged kn ee locked. Gen erally, edem a su bsides w ith in 10– 14 days. Th e m ajor ben e t is to th e com ort o th e patien t an d n ot on ly to th e ractu re. Th e older th e patien t, th e m ore debilitatin g a lon g period o bed con n em en t m ay be. Th e low m ortality, decreased m orbidity, an d m ore rapid disch arge rom h ospital m ake ractu re bracin g treatm en t attractive or th e patien t, ph ysician , an d h ospital, i n on operative treatm en t is u sed.

43

racture s, dislocations, and subluxations of the lower e xtre mit

5

ia p

s e a l t i ia

am i Moshe iff

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Fractu res o th e tibial sh a t are th e m ost com m on lon g bon e ractu res, an d also th e m ost com m on type o open ractu res. Tibial-sh a t ractu res m ay a ect kn ee align m en t, stability, an d stren gth . Com pared to oth er types o ractu re, th ese ractu res are associated w ith a h igh in ciden ce o in ection , delayed u n ion , n on u n ion , or m alu n ion . Th e so t-tissu e en velope is th e m ost im portan t com pon en t in th e evalu ation an d su bsequ en t care o tibial ractu res. 5

In d ica t io n s fo r n o n o p e ra t ive t re a t m e n t

Spiral ractu res o th e tibial diaph ysis can be treated n on operatively. How ever, som e sh orten in g m u st be expected (th e in itial x-ray u su ally sh ow in g h ow m u ch sh orten in g to be expected). Sign i can t displacem en t or an gu lation , particu larly or distal ractu res, in dicates an in creased risk o secon dary displacem en t w ith n on operative treatm en t. Malrotation is a risk th at m u st be looked or an d corrected, particu larly du rin g th e rst w eek o n on operative treatm en t. Ta le 3 provides an overview o th e variou s types o diaph yseal tibial ractu res an d th e available treatm en t option s. 5

No n o p e ra t ive t re a t m e n t

Option s or n on operative treatm en t or diaph yseal tibial ractu res in clu de: • Plaster o Paris cast • Sarm ien to brace. 5

Pla s t e r o f Pa ris ca s t

In acu te ractu re treatm en t o diaph yseal tibial ractu res, plaster o Paris (POP) is th e stan dard cast m aterial. Tw o grades o in itial displacem en t can be de n ed:

/ T classi cation

B

Ta le

44

3

Type of fracture

racture pattern

• Min im al displacem en t: In th ese cases th e ractu re can be brou gh t in to an acceptable position sim ply by correctin g an gu lation . Th e sh orten in g th at w ill occu r is acceptable becau se th e h ealed bon e is stable at th is len gth an d w ill n ot sh orten an y u rth er. An in tact so t-tissu e h in ge can u su ally be predicted on th e con cave side o th e ractu re. Un ion u su ally w ill occu r w ith ou t problem s an d sou n d con solidation u n der con servative m eth ods w ill u su ally be presen t w ith in 3 m on th s • Displacem en t w ith overridin g: In su ch cases, th e attach m en t to th e in terosseou s m em bran e w ill be ru ptu red an d th is im portan t path w ay or th e bridgin g by callu s o on e ragm en t to th e oth er w ill be destroyed. Delayed u n ion w ill m ost likely occu r. Sim ple correction o an gu lation does n ot su ce in th is type o ractu re. Th e restoration o len gth an d apposition by at least h al diam eters is n ecessary. Mech an ical m ean s m u st be u sed in order to ren der th e redu ced position stable. In th e secon d grou p o ractu res o both tibia an d bu la, th e n eed to preven t redisplacem en t a ter redu ction is particu larly im portan t i th e lim b is en cased in a POP cast. I a ractu re o th e tibia an d bu la h as been redu ced by applyin g traction an d a POP cast, th ere w ill be a grave risk o ven ou s obstru ction in side th e plaster sh ou ld th e ractu re redisplace on ce th e traction is rem oved (see ch apter 4 Th rom bosis proph ylaxis). Traction both len gth en s th e leg an d m akes it n arrow er, th u s w h en traction is released, th e th ickn ess o th e lim b in side th e plaster w ill in crease at th e sam e tim e it sh orten s. Th e viciou s circle o ven ou s obstru ction , w h ich can resu lt rom th is type o "plu ggin g", is very dan gerou s,

Nonoperati e treatment

perati e treatment

Simple fractures

nly in rare cases ondisplaced Fractures without shortening Fractures with intact fibula no angulation Low-demand patients

ecommended treatment

Wedge fractures

nly in rare cases ondisplaced Fractures without shortening Fractures with intact fibula no angulation Low-demand patients

ecommended treatment

Complex fractures

nly in rare cases ondisplaced Fractures without shortening Fractures with intact fibula no angulation Low-demand patients

ecommended treatment

Ove rvie w of the various t pe s of diaph se al tibial fracture s and the available tre atm e nt options

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

ami Moshe iff, uan Manue l Concha

5

Sa rm ie n t o fra ct u re ra ce p la s t e r o f Pa ris o r s e m irigid s n t e t ic

Im m obilization in a skin tigh t lon g leg cast an d im m ediate w eigh t bearin g w as rst reported by Deh n e et al [5]. Oth er n on operative w eigh t bearin g m odi cation s developed later on . Sarm ien to, reason in g th at th e prin ciple o a below -kn ee cast/ orth osis m igh t be applicable, developed th e patella ten don bearin g cast or tibial ractu res [6] (see ch apter 16.8 Sarm ien to (patella ten don bearin g) cast u sin g plaster o Paris ( ig 5 )). Th e average h ealin g tim e w as 14.5 w eeks or closed ractu res an d 16.7 w eeks or open ractu res. Th e average lim b sh orten in g in th e cast w as 6.35 m m . It is n ow eviden t th at th e patella ten don w as n ot carryin g as m u ch w eigh t as th ou gh t. It is th e m odelin g o th e cast as w ell as pressu re con sideration s—th e h ydrau lic e ect—w ith in th e leg th at provide stability or th e ractu re ragm en ts.

ig

5

Exam ple of a Sarm ie nto pe talla te ndon be aring cast

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Th e u n ction al below -kn ee orth osis (Sarm ien to brace) w as th e n ext logical developm en t in th e m an agem en t o tibial ractu res. Th e tibia is stabilized w ith a coverin g o th erm oplastic m aterial or a sem irigid syn th etic brace (see ch apter 16.9 Sarm ien to tibial brace u sin g syn th etic, com bicast tech n iqu e), leavin g a ree an kle join t. Th e brace is th en attach ed to th e oot cast. Th e resu lts h ave been sh ow n to be equ al to th ose u sin g th e con ven tion al plaster tech n iqu e [7]. How ever, th e Sarm ien to brace, leavin g th e an kle ree, is n ot applied im m ediately. In order to avoid problem s o edem a in th e oot an d an kle, th e en tire extrem ity is con ven tion ally cast or abou t 2 w eeks (see ch apters 16.6 Lon g leg cast u sin g plaster o Paris; an d 16.7 Lon g leg cast u sin g syn th etic, com bicast tech n iqu e). Du rin g th is tim e, th e extrem ity is in term itten tly elevated, an d th e prim ary con sideration is con trol o sw ellin g. A patella ten don bearin g (PTB) totalcon tact cast is th en applied or an addition al 2 w eeks (see ch apter 16.8 Sarm ien to (patella ten don bearin g) cast u sin g plaster o Paris), an d w eigh t bearin g is allow ed an d en cou raged. I n o edem a is presen t at th is tim e, th e cast m ay be rem oved an d th e orth osis applied. Th e tibia is stabilized w ith a coverin g o th erm oplastic m aterial or sem irigid syn th etic cast (see ch apter 16.9 Sarm ien to tibial brace u sin g syn th etic, com bicast tech n iqu e ( ig 6 )). Th u s, ractu re treatm en t by orth osis begin s at abou t th e th w eek.

d

especially du rin g th e rst vital 24 h ou rs a ter redu ction . Most o ten , attem pts to assess th e circu lation by pressin g on a toe in order to observe th e retu rn o blood in to th e blan ch ed area are u n reliable. Severe postoperative pain m u st n ot be regarded as a n orm al sequ el ollow in g th e satis actory redu ction an d xation o a ractu red tibia. An y patien t th at despite an algesia is n ot ren dered com ortable a ter redu ction o th e ractu re m igh t be su erin g rom seriou s vascu lar com plication s or even com partm en t syn drom e. Th is m u st be diagn osed w ith in th e rst 6 h ou rs a ter application o th e POP cast. Th e loss o sen sation an d/ or active m ovem en t o th e toes are both seriou s sign s even in th e presen ce o w h at m ay appear to be good circu lation w h en ju dged by pressu re o th e n ger on th e n ail bed o a toe (see topic 11 in ch apter 3 Prin ciples o castin g; an d ch apters 4 Th rom bosis proph ylaxis; 16.5 Dorsal lon g leg splin t u sin g plaster o Paris; 16.6 Lon g leg cast u sin g plaster o Paris; an d 16.7 Lon g leg cast u sin g syn th etic, com bicast tech n iqu e).

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Th e advan tage o ch an gin g to th e orth osis is th at th e an kle can be m obilized. Th e position o th e an kle join t is critical as m otion at th e ractu re site, com pelled by di eren ces in th e axis o th e rotation o th e an kle an d th e orth osis, m u st be preven ted. Wearin g o th e orth osis is con tin u ed u n til th e ractu re is h ealed.

ig

6

Exam ple of a Sarm ie nto tibial brace

45

racture s, dislocations, and subluxations of the lower e xtre mit

is t a l t i ia

am i Moshe iff

Distal tibial ractu res are prim arily located w ith in a squ are based on th e w idth o th e distal tibia. Man y ractu res o th e distal tibia h ave severe con com itan t so t-tissu e com prom ise. It is recom m en ded to assess th e so t-tissu e con dition , sen sation , an d m otor u n ction in th e oot as w ell as to look ou t or sign s o com partm en t syn drom e, w h ich m ay develop som etim e a ter in ju ry. Grossly displaced ractu res an d dislocation s m u st be redu ced im m ediately an d tem porarily stabilized, u sin g a join t-bridgin g extern al xator.

6

No n o p e ra t ive t re a t m e n t

Non operative treatm en ts or ractu res o th e distal tibia in clu de: • Traction • Man u al redu ction • Casts. 6

Tra ct io n

Traction can be u sed w h ere w eigh t is applied at th e calcan eu s u sin g a Stein m an n pin in order to create redu ction ( ig ).

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In d ica t io n s fo r n o n o p e ra t ive t re a t m e n t

De n itive n on operative treatm en t w ith a cast is rarely in dicated or distal tibial ractu res. Th e n on operative treatm en t m ay, h ow ever, be adequ ate in n on displaced or m in im ally displaced ractu res th at are stable. Presen ce o a h igh su rgical risk obviou sly is an oth er in dicator or n on operative treatm en t in oth er ractu re types. Stabilizin g th e ractu re in a cast m ay be u sed or in itial m an agem en t u n til th e so t-tissu e situ ation allow s open redu ction an d in tern al xation . In h igh ly u n stable ractu res, th e cast m ay n ot su ce in order to m ain tain redu ction an d preven t sh orten in g. Su ch ractu res w ill n eed to be stabilized w ith an extern al xator. provides an overview o th e di eren t types o distal tibial ractu res an d th e available treatm en t option s.

Ta le

4

/ T classi cation

B

Ta le

46

4

Type of fracture

ig

Traction of the distal tibia

racture pattern

Nonoperati e treatment

perati e treatment

xtraarticular

ondisplaced closed stable fracture Significant comorbidities (high anesthesia risk) Compromising medical conditions (diabetes neurovascular diseases) Soft-tissue condition preventing surgical intervention onambulatory patient

ecommended treatment

Partial articular

ondisplaced closed stable fracture Significant comorbidities (high anesthesia risk) Compromising medical conditions (diabetes neurovascular diseases) Soft-tissue condition preventing surgical intervention onambulatory patient

ecommended treatment

Complete articular

ondisplaced closed stable fracture Significant comorbidities (high anesthesia risk) Compromising medical conditions (diabetes neurovascular diseases) Soft-tissue condition preventing surgical intervention onambulatory patient

ecommended treatment

Ove rvie w of the diffe re nt t pe s of distal tibial fracture s and the available tre atm e nt options

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

ami Moshe iff, uan Manue l Concha

6

a n u a l re d u ct io n

Som e su rgeon s in stead o u sin g gravity to add positive su pport in ractu re redu ction pre er to rearran ge th e e ective orces so th at th e e ect o gravity is elim in ated. In an an kle ractu re, th is can be ach ieved by carryin g ou t th e redu ction w ith th e tibia in th e vertical position by h an gin g th e low er leg over th e en d o a table. Th e ph ysician th en h olds th e oot arou n d its m iddle section rom plan tar an d m edial w ith on e h an d an d graspin g th e h eel w ith th e oth er. Redu ction is ach ieved by gen tle traction an d by align in g th e oot to m atch th e axis o th e low er leg, th ereby also correctin g rotation ( ig ). 6

3 Pla s t e r o f Pa ris ca s t

For th e in itial pu rpose o ractu re redu ction , on ly su cien t plaster sh ou ld be applied to be stron g en ou gh to m ain tain redu ction tem porarily on ce th e plaster h as set. Syn th etic or

e n i

In regard to n ish in g th e POP cast at th e toes, it is u su ally best to leave th e toes ree by stoppin g th e plaster at th e m etatarsoph alan geal join ts. A plat orm u n der th e toes, u n less m ade very care u lly, o ten produ ces a cram ped position . In secon dary treatm en t, syn th etic m aterial can also be u sed (see ch apters 16.11 Dorsal sh ort leg splin t u sin g syn th etic; 16.12 Sh ort leg cast u sin g rigid syn th etic; an d 16.13 Sh ort leg cast u sin g syn th etic, com bicast tech n iqu e).

a

ig Ma ing use of gravit in orde r to he lp re duce the fracture This is onl possible if tre atm e nt is carrie d out on the da of in ur , with the fracture in t pical de form it and be fore swe lling has se t in Ade uate ane sthe sia m ust be adm iniste re d

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Th e im portan ce o recogn izin g th e role o gravity in redu ction de orm ity can n ot be better illu strated th an by th e exam ple o a distal tibial ractu re. By h oldin g th e oot in on e h an d w ith th e h eel restin g in th e palm , w ith th e oot an d leg h eld h orizon tally an d in extern al rotation , th e an kle w ill spon tan eou sly all in to th e position o redu ction ( ig ). On ly i su rgeon s tru ly u n derstan d h ow u n n ecessary th e u se o m u scu lar orce is, w ill th ey really appreciate th e m ech an ics o th e ractu re an d th e n ecessity or patien ts to presen t as early as possible a ter in ju ry. At rst, it is im portan t n ot to redu ce an y ractu re by ph ysical m ovem en ts bu t to assess th e in f u en ce o variou s m ech an ical actors on each in ju ry as an in dividu al case.

sem irigid syn th etic cast m aterial is n ot recom m en ded or redu ced ractu res. Du rin g th is application , n o e ort sh ou ld be spen t on th e u ltim ate n ish o th e u pper an d low er lim its o th e plaster, w h ich w ou ld on ly be a w aste o tim e an d in vite settin g o th e cast be ore ractu re redu ction h as been ach ieved. Havin g com pleted th e speedy application o th e in itial plaster ban dages, th e su rgeon n ow takes over rom th e assistan t an d “ eels” th e ractu re by m ovin g it abou t in side th e w et plaster; rom th e previou s an alysis o th e ractu re, h e or sh e again sh ou ld be able to recogn ize th e sen sation o redu ction , alth ou gh th ese im pression s m ay n ow be a little m u f ed by th e plaster (see ch apter 16.10 Dorsal sh ort leg splin t u sin g plaster o Paris). Havin g recogn ized th e sen sation o redu ction , th e ph ysician n ow h olds th e redu ction w ith ou t an y u rth er m ovem en t u n til th e plaster h as set. Du rin g th is tim e, u sin g gravity, th e assistan t m ain tain s th e oot an d leg in extern al rotation w h ile th e su rgeon su pports th e oot w ith h is or h er h an d below th e h eel. Th e cast is com pleted by n ish in g th e top an d bottom , an d applyin g extra castin g m aterial in order to in crease th e th ickn ess, i n ecessary.

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The use of gravit in re duction

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ig a Manual re duction is pe rform e d on the hanging le g, with the ne e e xe d in orde r to re duce the pull on the Achille s te ndon e duction is achie ve d b ge ntle traction a and b aligning the foot to m atch the axis of the lowe r le g, the re b also corre cting rotation

4

racture s, dislocations, and subluxations of the lower e xtre mit

oot

uan Manue l Concha

Bon e an d ligam en t in ju ries th at a ect th e oot are com m on , resu ltin g especially rom sports activities, job acciden ts, an d h igh -en ergy trau m a cau sed by tra c acciden ts. Establish in g a proper diagn osis is cru cial in order to determ in e th e m ost appropriate treatm en t.

Th e m ost requ en t in ju ries o th e h in d oot in clu de ractu res o th e talu s, calcan eu s, an d su btalar dislocation s.

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displacem en ts, th rou gh th eir e ects on join t u n ction an d align m en t, m ay cau se oot de orm ity, arth rosis, an d sign i can t u n ction al im pairm en t. Soon a ter in ju ry, so t tissu es m u st be evalu ated care u lly, as th e pressu re on th e skin rom bon y de orm ity, an d associated edem a, m ay lead to skin n ecrosis, slou gh , an d secon dary in ection . Displaced ractu res o th e talar n eck are associated w ith avascu lar n ecrosis o th e talar body, bu t th e u rgen cy o ractu re xation h as recen tly been called in to qu estion [8]. Non eth eless, it is im portan t to redu ce dislocation s (su btalar an d an kle) as soon as possible.

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Ta lu s fra ct u re s

Fractu res o th e talu s are rare, yet th e in tegrity o th e talu s is essen tial or proper oot u n ction . Even sm all ractu re awkins classi cation

Type of fracture

racture pattern

Haw kin s classi cation [9] describes ou r types o talu s ractu res accordin g to th e degree o displacem en t, an d also provides th e available th erapeu tic option s (see Ta le 5 a c ). Nonoperati e treatment

perati e treatment

Talar neck fracture

Type I

nly completely nondisplaced

ecommended treatment

Type II

Displaced multifragmentary

ot indicated

ecommended treatment

Type III

Displaced multifragmentary

ot indicated

ecommended treatment

Type IV

Displaced multifragmentary

ot indicated

ecommended treatment

Ta le

4

ondisplaced

5a

Ove rvie w of the four t pe s of talus fracture s according to

aw ins and the available tre atm e nt options

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Authors

ami Moshe iff, uan Manue l Concha

/ T classi cation

Type of fracture

racture pattern

Nonoperati e treatment

perati e treatment

Ankle joint involvement

ot indicated

ecommended treatment

C2

Subtalar involvement

ot indicated

ecommended treatment

C3

Ankle subtalar involvement

ot indicated

ecommended treatment

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Talar body fracture C1

Ta le

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Ove rvie w of the C t pe talar bod fracture s according to the AO OTA racture and Dislocation Classi cation

ateral posterior process fractures

Type of fracture

racture pattern

Nonoperati e treatment

perati e treatment

Lateral process

ondislocated

ption

ption

Posterior process

ondislocated

ption

ption

Lateral process

Dislocated

ot indicated

ecommended treatment

Posterior process

Dislocated

ot indicated

ecommended treatment

Ta le

5c

Ove rvie w of late ral and poste rior proce ss fracture s and possible nonope rative tre atm e nt options

4

racture s, dislocations, and subluxations of the lower e xtre mit

Ca lca n e u s fra ct u re s

Th e m an agem en t o calcan eu s ractu res is still con troversial [11]. Recen t advan ces in diagn ostics, su rgical tech n iqu es, so t-tissu e care, as w ell as im plan ts, h ave h elped to ach ieve better resu lts in th e treatm en t o com plex articu lar ractu res o th e calcan eu s. Displaced tu berosity ractu res th at carry th e th reat o skin n ecrosis are an accepted in dication or im m ediate ractu re redu ction an d xation .

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On ly tru ly n on displaced type I ractu res sh ou ld be treated n on operatively by m ean s o im m obilization in a n on w eigh t bearin g sh ort leg cast, an d strict periodic x-ray con trol. Im m obilization splin ts can in itially be u sed as prim ary care, an d im m ediately a ter su rgery or com ort as w ell as to preserve n eu tral oot align m en t u n til reh abilitation can be in itiated [10] (see ch apters 16.10 Dorsal sh ort leg splin t u sin g plaster o Paris; 16.11 Dorsal sh ort leg splin t u sin g syn th etic; 16.12 Sh ort leg cast u sin g rigid syn th etic; an d 16.13 Sh ort leg cast u sin g syn th etic, com bicast tech n iqu e).

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/ T classi cation

racture pattern

Nonoperati e treatment

perati e treatment

xtraarticular fractures

A

C

ssex-Lopresti

Ta le

5

Type of fracture

6

Avulsion fracture of the calcaneal tuberosity

ondisplaced

ecommended treatment

Involving the anterior process

ondisplaced

ecommended treatment

Articular

ondisplaced

ecommended treatment

oint depression

ot indicated

ecommended treatment

Tongue type

ot indicated

ecommended treatment

Ove rvie w of the various t pe s of calcane us fracture s and the available tre atm e nt options

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

ami Moshe iff, uan Manue l Concha

Su btalar dislocation s are im portan t in ju ries gen erally cau sed by orced oot in version or eversion . Th ey a ect both th e su btalar an d talon avicu lar join ts ( ig ).

Im m obilization splin ts are u se u l at th e in itial stage o th e treatm en t as w ell as th e postsu rgical period. I n on operative treatm en t is selected, a splin t or cast (see ch apters 16.10 Dorsal sh ort leg splin t u sin g plaster o Paris; 16.11 Dorsal sh ort leg splin t u sin g syn th etic; 16.12 Sh ort leg cast u sin g rigid syn th etic; an d 16.13 Sh ort leg cast u sin g syn th etic, com bicast tech n iqu e) to su pport n eu tral oot align m en t m ay be u sed at rst, bu t it sh ou ld n ot preven t early m obilization o th e an kle an d oot (see ch apters 16.13 Sh ort leg cast u sin g syn th etic, com bicast tech n iqu e), w h ile avoidin g w eigh t bearin g or 2–3 m on th s.

Isolated ractu res are u n com m on an d it is im portan t to be on th e lookou t or th e possibility o oth er associated in ju ries [13]. Navicu lar ractu res are relevan t i th e talon avicu lar articu lar su r ace as w ell as th e posterior tibial ten don in sertion are com prom ised. Cu boid ractu res are cau sed by axial orce alon g th e lateral oot colu m n an d rarely are isolated in ju ries. Navicu lar ractu res are o ten in du ced by h igh -en ergy in ju ries ( ig ).

Application o a oot cast allow s u n restricted m obilization o th e an kle join t (see ch apters 16.18 Foot cast u sin g syn th etic, com bicast tech n iqu e; an d 16.19 Rem ovable oot cast u sin g syn th etic, com bicast tech n iqu e).

X-rays an d CT scan s are im portan t or th e evalu ation o m id oot ractu res. Th e m an agem en t ocu ses on restorin g m id oot align m en t an d stability, especially preservin g th e len gth o th e m edial an d lateral colu m n s.

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Early redu ction is im portan t in order to avoid vascu lar com prom ise o th e so t tissu es located above th e in ju ry. Th is m an eu ver can be don e w ith th e kn ee f exed an d w ith rm lon gitu din al traction . Gen erally, th e in ju red join t is stable a ter redu ction . Im m obilization is ach ieved w ith a splin t (see ch apters 16.10 Dorsal sh ort leg splin t u sin g plaster o Paris; 16.11 Dorsal sh ort leg splin t u sin g syn th etic; an d 16.13 Sh ort leg cast u sin g syn th etic, com bicast tech n iqu e) or a ew days, ollow ed by active ran ge o m otion exercises an d, in itially, protected w eigh t bearin g.

e

Open redu ction is recom m en ded in displaced articu lar ractu res, w ith Böh ler’s an gle in version , or articu lar su r ace displacem en t [12]. Ta le 6 provides an overview o th e variou s types o calcan eu s ractu res an d th e available treatm en t option s.

3 Su t a la r d is lo ca t io n s

d

Radiograph ic evalu ation , in clu din g CT, is u se u l in order to evalu ate an d classi y th e ractu re an d plan its m an agem en t. Treatm en t m u st be in dividu alized accordin g to: • Age o th e patien t • Activity level • Bon e con dition • Type o ractu re • State o th e so t tissu es.

i

Authors

ones

Compression force from first metatarsal

Compression force from second metatarsal

one of maximal shear stress

ody weight component through talus ig lar oints

Subtalar dislocations affe ct both subtalar and talonavicu

ig Traumatic im pact on the navicular bone The one of m aximal she ar stre ss is locate d at the unction of the m iddle to the late ral third

5

racture s, dislocations, and subluxations of the lower e xtre mit

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I n ot displaced, m id oot ractu res can be treated n on operatively, u sin g a sh ort leg cast (see ch apters 16.10 Dorsal sh ort leg splin t u sin g plaster o Paris; an d 16.11 Dorsal sh ort leg splin t u sin g syn th etic), or w ith u n restricted m ovem en t o th e an kle join t (see ch apters 16.18 Foot cast u sin g syn th etic, com bicast tech n iqu e; an d 16.19 Rem ovable oot cast u sin g syn th etic, com bicast tech n iqu e), avoidin g w eigh t bearin g or th e rst 6 w eeks. Displaced ractu res or u n stable join ts sh ou ld be treated w ith an open redu ction an d in tern al xation (ORIF). 3

o re fo o t m e t a t a rs a ls , p a la n ge s

Th e ore oot com prises th e tarsom etatarsal join t as w ell as th e m etatarsals, ph alan ges, an d join ts th at con n ect th em . Th e tarsom etatarsal join t (TMT), o ten re erred to as Lis-

ran c’s join t in h on or o th e su rgeon th at described am pu tation at th at level, is a com plex osteoligam en tou s system th at in volves th e u n ion o th e rst th ree m etatarsals w ith th e cu n ei orm bon es, an d th e ou rth an d th w ith th e cu boid. 3

Ta rs o m e t a t a rs a l

is fra n c s

o in t in u rie s

Lis ran c’s TMT join t in ju ries are u su ally produ ced by su dden , violen t tw ists o th e ore oot. I de orm ity or in stability is n ot obviou s, th ese in ju ries are easily overlooked, w ith disastrou s con sequ en ces [14]. Com m on ly, th e patien t presen ts w ith edem a an d pain in th e dorsal region o th e oot. De orm ity depen ds on th e degree o displacem en t. Ta le provides a classi cation o th e variou s types o TMT join t ractu res.

Type of fracture Type A

edial:

Total incongruity

All 5 metatarsals together displaced in a dorsolateral direction

Lateral:

Type 1

Homolateral complete

Type 2

Partial incongruity

Type C1

Homolateral incomplete

Type C2

Partial incongruity

Ta le Kuss in

5

Classi cation of the various t pe s of TMT oint fracture s and m odi e d b M e rson and ardcastle in

nly the first T Tjoint involved.

Lateral T Ts are also involved.

isfranc s The original isfranc s classi cation was done b

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

ue nu and

Klaus Dre sing, Pe te r Trafton

ami Moshe iff, uan Manue l Concha

On ly a proper redu ction o th e ractu re an d restoration o stability to th e in ju red join ts w ill perm it adequ ate pain - ree u n ction [14]. Th u s closed treatm en t is on ly in dicated or stable, accu rately redu ced, n on displaced in ju ries an d w ith n o com prom ise o th e so t tissu es. I stability o th e TMT join t com plex is con rm ed (stress x-rays), n on operative treatm en t is appropriate. Th is can be don e w ith a w ellm olded sh ort leg cast (see ch apters 16.10 Dorsal sh ort leg splin t u sin g plaster o Paris; 16.11 Dorsal sh ort leg splin t u sin g syn th etic; 16.12 Sh ort leg cast u sin g rigid syn th etic; an d 16.13 Sh ort leg cast u sin g syn th etic, com bicast tech n iqu e) an d n on w eigh t bearin g im m obilization or 6 w eeks. Th e cast sh ou ld be reapplied i it h as loosen ed du e to decreased edem a. X-rays m u st be taken in order to ch eck or u rth er displacem en t.

ig Sm all avulsion and oint space wide ning be twe e n the rst and se cond m e tatarsal base s

Im m obilization w ith a sh ort leg splin t in stead o a cast plays a role in th e in itial preoperative treatm en t as w ell as postoperative treatm en t (see ch apters 16.10 Dorsal sh ort leg splin t u sin g plaster o Paris; an d 16.11 Dorsal sh ort leg splin t u sin g syn th etic), an d can be u sed in itially in n on operative cases w ith sign i can t sw ellin g [16]. An oth er option is oot cast im m obilization (see ch apters 16.18 Foot cast u sin g syn th etic, com bicast tech n iqu e; an d 16.19 Rem ovable oot cast u sin g syn th etic, com bicast tech n iqu e). e

e t a t a rs a l fra ct u re s

n

3

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Th ese ractu res are requ en tly produ ced by a direct blow to th e oot, com m on ly a ectin g th e secon d, th ird, an d ou rth m etatarsals. Equ ally com m on are avu lsion ractu res o th e base o th e th m etatarsal an d n eck ractu res o th e secon d, th ird, an d th m etatarsals. Su pportin g ligam en ts attach ed to th e proxim al an d distal en ds o th e m etatarsals u su ally preven t displacem en t o sh a t ractu res o th e m iddle m etatarsals. Isolated ractu res o th e cen tral m etatarsals w ith little displacem en t can be treated w ith im m obilization in a w alkin g cast or 3 w eeks (see ch apters 16.12 Sh ort leg cast u sin g rigid syn th etic; an d 16.13 Sh ort leg cast u sin g syn th etic, com bicast tech n iqu e) ollow ed by a sem irigid oot cast or an oth er 3 w eeks (see ch apters 16.18 Foot cast u sin g syn th etic, com bicast tech n iqu e; an d 16.19 Rem ovable oot cast u sin g syn th etic, com bicast tech n iqu e). Moderate displacem en ts in th e ron tal plan e o th e cen tral m etatarsals are w ell tolerated. How ever, sign i can t displacem en t o th e rst or th e th m etatarsal requ ires redu ction an d percu tan eou s xation , or ORIF, as do u n stable ractu res w ith sh orten in g in order to preven t m aldistribu tion o w eigh t bearin g orces w ith tran s er o pressu re to th e m ore prom in en t m etatarsal h eads w ith resu ltin g m etatarsalalgia [17].

d

Th e x-ray im ages can vary betw een su btle in ju ries, sm all ) even bon e avu lsion s, an d join t space w iden in g ( ig to m ajor displacem en ts th at u su ally coin cide w ith sign i can t edem a an d m ay be associated w ith vascu lar lesion s ( ig 3 ). It is im portan t to ch eck or an in creased space betw een th e rst an d secon d m etatarsal in th e an teroposterior view , ractu res at th e base o th e secon d m etatarsal, or su btle bon y avu lsion s th at m ay in dicate sign i can tly u n stable ligam en t avu lsion s. In th e lateral an d obliqu e projection , th e align m en t betw een th e rst m etatarsal an d th e rst cu n ei orm m u st be observed care u lly as w ell as th e articu lation s o th e n avicu lar (talon avicu lar an d n avicu locu n ei orm ), w h ich m ay also be in volved in a TMT in ju ry.

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ig 3 Se ve re TMT oint displace m e nt x ra s and soft tissue condition

53

Fractu res o th e m etatarsal n ecks are produ ced by direct trau m a an d o ten in volve several m etatarsals. Usu ally, it is possible to ach ieve closed redu ction by traction an d con tain m en t in a w alkin g cast (see ch apters 16.12 Sh ort leg cast u sin g rigid syn th etic; 16.13 Sh ort leg cast u sin g syn th etic, com bicast tech n iqu e; 16.18 Foot cast u sin g syn th etic, com bicast tech n iqu e; an d 16.19 Rem ovable oot cast u sin g syn th etic, com bicast tech n iqu e); oth erw ise su rgical xation m ay be requ ired. Im proper redu ction s sh ou ld n ot be accepted, as th ey can a ect th e su pport an d biom ech an ics o th e oot [18].

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racture s, dislocations, and subluxations of the lower e xtre mit

Fractu res o th e th m etatarsal base deserve special atten tion . Treatm en t is based on th e location zon e ( ig 4 ): • Zon e 1: Tu berosity • Zon e 2: Metaph yseal-diaph yseal u n ion • Zon e 3: Proxim al diaph ysis. In ju ries in zon e 3 are u su ally atigu e ractu res (see ch apter 13 Overload in ju ries) [18].

2 1

ig

54

4

Treatm en t sh ou ld be in dividu alized, takin g in to accou n t th e site o th e ractu re as w ell as th e age an d activity level o th e patien t. • Fractu res in zon e 1 h ave a good blood su pply an d u su ally h eal w ith partial w eigh t bearin g in a com ortable sh oe or oot cast (see ch apters 16.18 Foot cast u sin g syn th etic, com bicast tech n iqu e; an d 16.19 Rem ovable oot cast u sin g syn th etic, com bicast tech n iqu e) • Fractu res in zon e 2 are u su ally m ore pain u l an d requ ire im m obilization . It is possible to u se a sh ort leg POP cast or 3–4 w eeks (see ch apters 16.10 Dorsal sh ort leg splin t u sin g plaster o Paris; 16.11 Dorsal sh ort leg splin t u sin g syn th etic; 16.12 Sh ort leg cast u sin g rigid syn th etic; an d 16.13 Sh ort leg cast u sin g syn th etic, com bicast tech n iqu e), ollow ed by a u n ction al m etatarsal brace/ cast u n til h ealin g is com plete (see ch apters 16.18 Foot cast u sin g syn th etic, com bicast tech n iqu e; an d 16.19 Rem ovable oot cast u sin g syn th etic, com bicast tech n iqu e) • Fractu res in zon e 3 h ave a greater risk o delayed u n ion or n on u n ion . Du e to th is, an d in view o th e patien t’s n eeds, su rgical xation m ay be an appropriate option [19].

3

The location one s for fracture s of the fth m e tatarsal base

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

ami Moshe iff, uan Manue l Concha

Type II lesion s can be treated by closed redu ction an d im m obilization or 3–4 w eeks in a sh ort low er-leg cast (see ch apters 16.10 Dorsal sh ort leg splin t u sin g plaster o Paris;

Type of fracture

Nonoperati e

Type I

The sesamoid complex and volar plate block the joint preventing closed reduction

Intersesamoid ligament

e n

rst MTP join t in to

i

Jah ss classi ed th e dislocation s o th e th ree types ( Ta le ) [20].

Metatarsoph alan geal dislocation s o th e lesser toes are rare an d u su ally on ly requ ire closed redu ction w ith traction an d im m obilization in a sem irigid oot cast or 3–4 w eeks (see ch apters 16.18 Foot cast u sin g syn th etic, com bicast tech n iqu e; an d 16.19 Rem ovable oot cast u sin g syn th etic, com bicast tech n iqu e).

e

Hyperexten sion sprain s o th e rst m etatarsoph alan geal (MTP) join t are requ en t, especially resu ltin g rom sports activities. Treatm en t is based on rest, coolin g (ice), an algesics, an d perh aps tapin g o th e rst to th e secon d toe. Usu ally discom ort is dim in ish ed by th e secon d or th ird w eek an d activity can progressively be resu m ed as tolerated.

16.11 Dorsal sh ort leg splin t u sin g syn th etic; 16.12 Sh ort leg cast u sin g rigid syn th etic; an d 16.13 Sh ort leg cast u sin g syn th etic, com bicast tech n iqu e) or a oot cast (see ch apters 16.18 Foot cast u sin g syn th etic, com bicast tech n iqu e; an d 16.19 Rem ovable oot cast u sin g syn th etic, com bicast tech n iqu e).

d

Me tatarsophalange al oint in urie s

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Authors

perati e e uiring open reduction with subse uent protection in a short leg cast

Abductor hallucis

Dislocation Flexor hallucis brevis (medial head) Type IIA

Sesamoid complete ruptures without fracture

elative indication

Type II

Fracture of the sesamoid adiographically the increased space between the sesamoids is the key to the classification

elative indication

Ta le

ahss classi cation of the dislocations of the rst MTP oint

55

racture s, dislocations, and subluxations of the lower e xtre mit

3 3 ra ct u re s o f t e p a la n ge s , a n d in t e rp a la n ge a l d is lo ca t io n s

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Fractu res o th e ph alan ges o th e h allu x are u su ally du e to direct trau m a. I n on displaced, th ey m ay be treated w ith sem irigid oot cast im m obilization or 3–4 w eeks (see ch apters 16.18 Foot cast u sin g syn th etic, com bicast tech n iqu e; 16.19 Rem ovable oot cast u sin g syn th etic, com bicast tech n iqu e; an d 16.20 First toe orth osis u sin g syn th etic, com bicast tech n iqu e). Displaced ractu res requ ire closed redu ction an d percu tan eou s xation , or ORIF. In terph alan geal join t dislocation s resu lt rom axial orces th at displace th e distal ph alan x dorsally. Th ey sh ou ld be redu ced w ith lon gitu din al traction an d im m obilized to th e adjacen t toe w ith an adh esive ban dage. Fractu res o th e lesser toe ph alan ges likew ise requ ire closed redu ction an d im m obilization to th e adjacen t toe or 3–4 w eeks ( ig 5 ).

ig toe

56

5

Su m m a r

am i Moshe iff, uan Manue l Concha

• Fractu res o th e h ip/ proxim al em u r presen t a m ajor cau se o m orbidity an d m ortality all over th e w orld • In m an y cases, th ese ractu res are best treated by operative in tern al xation , yet w h en ever th e risks o su rgery an d an esth esia are too great, n on operative treatm en t m u st be con sidered, an d th e ph ysician m u st be am iliar w ith closed redu ction m eth ods or di eren t ractu res • A variety o types o balan ced traction are th e pre erred n on operative treatm en t or ractu res o th e h ip, su ch as Ham ilton Ru ssell traction • Treatm en t o tibia ractu res o ten in volves a ractu re brace, an d treatm en t u sin g u n ction al (Sarm ien to) bracin g allow s or early w eigh t bearin g • Foot in ju ries are very com m on an d diagn osis is based on clin ical exam in ation o th e patien t an d diagn ostic im agin g (x-ray an d CT) • Closed m an agem en t in h in d oot ractu res is in dicated in n on displaced ractu res an d in patien ts w ith con train dication s to operative treatm en t • A h igh in dex o su spicion m u st exist to preven t th e Lis ran c´s in ju ry to be overlooked w ith disastrou s con sequ en ces or th e patien t • Isolated ractu res o th e cen tral m etatarsals w ith little displacem en t can be treated w ith im m obilization • Fractu res o th e th m etatarsal base deserve special atten tion , w ith treatm en t based on th e location zon e • Fractu res o th e ph alan ges, i n on displaced, can be treated w ith a sh ort period o im m obilization .

Toe phalange s fracture with im m obili ation to ad ace nt

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

ami Moshe iff, uan Manue l Concha

e fe re n ce s ASA ph ysical statu s classi cation s: a stu dy o con sisten cy o ratin gs. Anesthesiology. 1978; 49:239 –243. 2.

ne rt

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o ffm e ie r

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u r t e r re a d in g

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il T ,

a rs

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it s c i Cla n t o n T , Bu t le r

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r . Th e treatm en t o open

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t o n e n PP, e t a l

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

ebhard, Pe te r ichter, astian Sche ide rer

ebhard, Pe ter ichte r, astian Sche ide rer

In t ro d u ct io n

6

ia gn o s t ics

6 6

4

T o ra cic a n d lu m a r s p in e Stable fracture s Nonope rative tre atm e nt

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Ce r vica l s p in e Occipital cond le fracture s racture s of the C

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Nonoperative treatment of spinal fractures

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Nonope rative treatme nt of spine fracture s

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Authors

lorian

ebhard, Pe te r ichter, astian Sche ide rer

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Ce r vica l s p in e

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Man y in ju ries o th e cervical spin e are treated n on operatively. Depen din g on th e stability level, treatm en t option s ran ge rom im m obilization by cervical collars an d braces to h alo orth osis ( ig 3 ), or a Min erva or Diadem cast/ orth osis ( ig 3 ). Stern al-occipital-m an dibu lar type im m obilizers are th e m ost e ective in lim itin g th e u pper cervical spin e m otion o n on h alo devices [2].

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As w as stron gly su pported by Böh ler, spin e ractu res can be treated n on operatively. How ever, som e spin e ractu res, especially i th ey are u n stable, do requ ire su rgery [1]. Yet, in som e parts o th e w orld, even u n stable spin e ractu res h ave to be treated n on operatively becau se o a com plete lack o resou rces.

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Nonoperative treatment of spinal fractures

Osteoporotic ractu res, alth ou gh gen erally stable, con stitu te on e o th e exception s. Du e to old age an d im m obility, su ch patien ts are pron e to su er rom pn eu m on ia an d oth er com plication s w h en treated n on operatively. Th ere ore, m in im ally in vasive treatm en t sh ou ld be th e rst ch oice. Vertebral m etastases an d path ological ractu res sh ou ld also be treated su rgically. Th e h igh com orbidity o th ese patien ts requ ires ast stabilization an d pain redu ction in order to allow early m obilization .

ia gn o s t ics

Wh en exam in in g spin e in ju ries, th e x-ray assessm en t begin s w ith AP an d lateral im ages. Typically, an addition al CT scan is m an datory in order to classi y th e ractu re type an d to ch oose th e righ t treatm en t. Also, MRIs are in creasin gly u sed in order to gain u rth er in orm ation .

a ig

b 3

a

alo xator

a ig 3 a The Diade m brace tions as a Mine rva brace

b ithout the he adband, it func

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ccip it a l co n d le fra ct u re s

Stable occipital con dyle ractu res w ith in tact alar ligam en ts (type I an d II) are im m obilized in a pre abricated h ard collar or a sem irigid cu stom -m ade com bicast or 6 w eeks. I an avu lsion ractu re o th e alar ligam en ts exists (type III), th is resu lts in in creased axial rotation across both th e O/ C1 an d C1/ 2 join ts [3]. In th is case, in stability is detected an d th e ractu re is treated w ith eith er a h alo vest, a Min erva/ Diadem cast ( ig 3 3 ), or in tern al xation . Th e m ore requ en t atlas ractu res occu r rom axial loadin g o th e occipu t th at tran slates in to distraction o th e lateral m asses. Th is resu lts in rin g ten sion an d cau ses th e rin g to ail [4]. Th e treatm en t o atlas ractu res is based on th e in tegrity o th e tran sverse ligam en t as it plays a m ajor role in determ in in g atlan toaxial stability. Dickm an et al reported in ju ries in volvin g th e m idportion o th e tran sverse ligam en t or th e in sertion poin t at th e tu bercle (type I) as u n stable [5]. Th ese in ju ries are in capable o h ealin g w ith extern al im m obilization alon e. In con trast, ractu res an d avu lsion s in volvin g th e tu bercle or in sertion o th e tran sverse ligam en t (type II) h ave a good ch an ce o h ealin g w h en treated w ith a h alo vest or Min erva/ Diadem cast or 12 w eeks. Isolated bon y in ju ries o th e atlas are m ain ly treated n on operatively w ith a h ard collar or 6–12 w eeks. In cases o lateral-m ass displacem en t o m ore th an 7 m m , a h alo vest is recom m en ded. In 40–44% o cases, atlas ractu res are associated w ith axis ractu res [6–8]. In th is case, treatm en t is based on th e type o axis ractu re an d th e in tegrity o th e tran sverse ligam en t. Extern al im m obilization is recom m en ded u n less in stability is eviden t on u prigh t an d su pin e x-rays w h ile th e patien t is w earin g an orth osis (Min erva/ Diadem cast).

3 3

ra ct u re s o f t e C ra ct u re s o f t e o d o n t o id

Fractu res o th e odon toid process are th e m ost com m on o all axis ractu res an d o ten cau se atlan toaxial in stability [9]. Accordin g to th e An derson -D’Alon zo th ree-part system ( Ta le 3 ), type I in ju ries are treated w ith a h ard collar or sem irigid com bicast collar or 6 w eeks [10]. How ever, a reevalu ation or rotatory atlan toaxial in stability sh ou ld be carried ou t a ter 3 m on th s. Th e m an agem en t o type II an d type III odon toid ractu res rem ain s con troversial. Mü ller et al de n ed ractu res th at h ad a ractu re gap o less th an 2 m m , an in itial AP displacem en t o less th an 5 m m , an an gu lation o less th an 11°, an d less th an 2 m m displacem en t on lateral f exion / exten sion view s as stable [11]. Th ey sh ow ed a u sion rate o 73.7% or type II an d 85.7% or type III ractu res treated w ith n on rigid im m obilization . A m eta-an alysis com parin g th e operative w ith th e n on operative m an agem en t o acu te type II odon toid ractu res sh ow ed a sign i can tly

nderson and D lon o lassi cation of dontoid ractures

Type I Apical (tip) fracture of the dens

Type II ody fracture of the odontoid

Type III asilar fracture into the body of the axis

a ig

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Modi e d Mine rva cast

Ta le 3 fracture s

The Ande rson and D Alon o classi cation of odontoid

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

ebhard, Pe te r ichter, astian Sche ide rer

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a gm a n s fra ct u re

Th e trau m atic spon dylolisth esis o th e axis (Han gm an ’s ractu re) is th e secon d m ost com m on type o axis ractu res (38% ) [16]. For th erapeu tic aspects, th e E en di [17] an d Levin e [18] classi cation s h ave been establish ed ( Ta le 3 ).

ffendi lassi cation of Traumatic Spondylolisthesis of the e ine

is as modi ed by

Type I ondisplaced fractures and those with up to 3 mm of displacement and no angulation

Type II Displacement greater than 3 mm as well as angulation

Type IIA oderate degrees of displacement combined with severe angulation

Type III Unilateral or bilateral facet dislocations in addition to the bilateral posterior element fractures

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Patien ts o advan ced age sh ow a h igh er com plication rate an d low er cervical ran ge o m otion w h en treated w ith extern al im m obilization [13–15]. Th e au th ors advocate th at type II ractu res w ith displacem en t o less th an 4 m m an d an an gu lation < 10° sh ou ld be treated w ith a h alo vest or Min erva/ Diadem cast or 6 w eeks. Correspon din gly, im m obilization m ay be carried ou t or stable type III odon toid ractu res.

Type I in ju ries com prise m in im ally displaced (< 3 m m ) ractu res o th e pars in terarticu laris. Th e disc space below th e axis is n orm al an d stable. Type II in ju ries sh ow a displacem en t o th e an terior body (> 3 m m ) w ith an abn orm al disc space (th e disc at C2/ 3 is a ected). With in th e type II grou p o E en di et al, Levin e iden ti ed in ju ries th at h ave sligh t or n o tran slation , bu t severe an gu lation (type IIA). Hyperexten sion an d axial loadin g leads to ru ptu re o th e disc an d th e an terior lon gitu din al ligam en t, resu ltin g in in stability. Type I an d type II in ju ries m ay be treated w ith a cervical brace or sem irigid com bicast collar or 6 w eeks. For th e redu ction o type II in ju ries, th e exten sion o th e cervical spin e w ith in th e orth osis is essen tial. Type IIA in ju ries m ay be treated w ith h alo im m obilization or Min erva/ Diadem cast i th e align m en t can be m ain tain ed. Th e h igh ly u n stable type III in ju ries are relatively rare. Here th e acets at C2/ 3 are dislocated an d locked, m ain tain in g th e body o C2 in a position o f exion w ith th e disc space at C2/ 3 open posteriorly. Type III in ju ries gen erally requ ire operative stabilization .

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h igh er u sion rate or operative th erapy com pared w ith extern al im m obilization or patien ts over th e age o 44–55. How ever, th e u sion rate w as over 80% or patien ts u n der th e age o 45–55, regardless o treatm en t m odality. Th e u sion rate in n on operative m an agem en t o ers com parable resu lts in an teriorly displaced ractu res an d displacem en t o less th an 4–6 m m [12].

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Isolated ractu res o th e C2 vertebral body m ay be treated w ith a h ard collar or sem irigid com bicast collar or 6 w eeks i th e ractu re orien tation is coron al (type I) or sagittal (type II) [19]. On ly in h igh ly displaced ractu res cau sin g sten osis o th e vertebral artery is h alo im m obilization or a Min erva/ Diadem cast requ ired. Th e teardrop ractu re o C2 (type III) gen erally occu rs a ter h igh -en ergy trau m a w ith h yperexten sion o th e cervical spin e [20]. Pu rely an terior ractu res o C2 h ave n o im pact on stability an d can be im m obilized w ith a h ard collar or sem irigid com bicast collar. How ever, i th e ractu re con tin u es in to th e C2/ 3 in tervertebral disc an d th e com m on posterior vertebral ligam en t, leadin g to C2/ 3 in stability, operative treatm en t is requ ired. Th is type o in ju ry sh ou ld n ot be con u sed w ith teardrop ractu res occu rrin g in th e low er cervical spin e as th e resu lt o a com pression -f exion m ech an ism . Th ese ractu res are sign i can tly m ore u n stable an d, th ere ore, h ave to be treated operatively [21].

Ta le 3 Effe ndi classi cation of traum atic spond lolisthe sis of the axis angman s fracture as m odi e d b e vine ,

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4 Sp in o u s p ro ce s s a n d t ra n s ve rs e p ro ce s s fra ct u re s

Spin ou s-process ractu res an d tran sverse-process ractu res are stable, an d so so t collar im m obilization or 6 w eeks is su cien t. How ever, a posterior ligam en tou s in ju ry m igh t coexist i th e spin ou s-process ractu re w as cau sed by a f exion m ech an ism . In th is case, su rgical stabilization m ay even be m an datory. Th e treatm en t o lateral-m ass ractu res depen ds on th e n eu rological statu s o th e patien t. In th e case o a spin al-cord in ju ry, th e ractu re is alw ays con sidered as u n stable an d operative treatm en t is requ ired. In isolated root in ju ries, n on operative treatm en t is possible as lon g as th e ractu re does n ot com prom ise th e n eu ral oram en . Th ereore, th e patien t can be im m obilized w ith a h ard collar, stern al-occipital-m an dibu lar im m obilizer ( ig 3 4 ) or Min erva/ Diadem cast. Com pression or bu rst ractu res are also possible can didates or extern al m an agem en t. How ever, on e sh ou ld be aw are th at th ese in ju ries ten d to resu lt in kyph osis an d, th ere ore, th e orth osis m u st su pply a good exten sion m om en t an d m u st be rigid [22].

a ig 3 4 a im m obili e r

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Wh en it com es to ractu res o th e C2 in ch ildren , n on operative treatm en t is a good option even w ith u n stable cervical spin e ractu res or lu xation . Min erva/ Diadem casts are con sidered m ost e ective ( ig 3 5 ).

b Miami ce rvical brace ste rnal occipital m e ndiobular

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3 5 Diade m cast in a e ar old bo

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

ebhard, Pe te r ichter, astian Sche ide rer

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St a le fra ct u re s

Accordin g to th e Magerl AO Classi cation o Spin e In ju ries [23], stable ractu res in clu de th e ollow in g: • A1.1 En dplate im paction : Th is ractu re occu rs du e to axial com pression an d is o ten seen in osteoporotic spin es. Th e posterior w all o th e vertebra is in tact. Th e spin al can al is n ot a ected. How ever, th e h eigh t o th e vertebra is redu ced

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b 3 6a

Thoracolum bar orthosis

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No n o p e ra t ive t re a t m e n t

Pain con trol an d m obility restriction are im portan t in th e early ph ase a ter trau m a. For u rth er pain redu ction an d stabilization o th e spin e, a corset, eg, a th ree-poin t corset, m ay be w orn (see ch apters 17.1 Corset u sin g plaster o Paris; 17.2 Corset u sin g syn th etic, com bicast tech n iqu e; an d 17.3 Rem ovable corset u sin g syn th etic, com bicast tech n iqu e) an d see ig 3 .

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Th e m ajority o th oracic an d lu m bar spin e ractu res h ave to be treated operatively becau se o th eir in stability an d th e risk o n eu rological dam age. Th e goal o every th erapy sh ou ld be pain redu ction , early m obilization , avoidan ce o m u scu lar atroph y, as w ell as th e preven tion o n eu rological dam age. Stable ractu res w ith ou t n eu rological dam age sh ou ld be treated n on operatively w ith or w ith ou t a corset ( ig 3 6 ). Kyph oplasty, ie, dorsal an d/ or ven tral stabilization , sh ou ld be per orm ed w h en th e ractu res are u n stable.

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Most spin e ractu res are located in th e th oracolu m bar area becau se o th e tran sition zon e betw een th e xed kyph otic th oracic spin e an d th e relatively f exible lordotic lu m bar spin e.

• A1.2 Wedge im paction ractu res: Th is ractu re is also du e to axial com pression . Th e posterior colu m n w all o th e vertebra is in tact. Th e loss o th e h eigh t can be eith er located in th e u pper part o th e vertebra, in th e in erior part o th e vertebra, or an terolaterally • A2.1 Sagittal split ractu res: Th e vertebral body is split in th e sagittal plan e w ith variou s degrees o displacem en t. Th e posterior w all stays u n h arm ed. Depen din g on th e degree o displacem en t, su rgery m ay be n ecessary • A2.2 Coron al split ractu res: Th e vertebral body is split in th e coron al plan e. Th e posterior w all stays u n h arm ed. Depen din g on th e degree o displacem en t, su rgery m ay be n ecessary.

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Im m obili ation afte r fracture re duction in ve rte bral

a Corse t using plaste r of Paris Corse t using s nthe tic, com bicast te chni ue c d e m ovable corse t using s nthe tic, com bicast te chni ue

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In addition to th e stable ractu res ou tlin ed by Magerl, type A1.3 ractu res can also be treated n on operatively as lon g as th e resou rces are available, an d especially w ith ch ildren an d adolescen ts ( ig 3 ). How ever, th e ractu re m u st rst be redu ced in vertebral h yperlordosis. As com pression ractu res o th e lu m bar spin e o ten resu lt in kyph osis, by u sin g lu m bar h yperlordosis th e ractu res are redu ced, an d th e reten tion is th en secu red by th e corset in h yperlordosis.

Radiological reevalu ation sh ou ld be con du cted a ter 7 days, 14 days, an d 6 w eeks in order to ascertain th at th e ractu re rem ain s stable. Th is can eith er be don e by x-ray or CT scan . A ter 6 w eeks, u ll m otion is allow ed. provides an overview o th e variou s types o th oracic an d lu m bar spin e ractu res an d th e available treatm en t option s [23]. Ta le

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Patie nt positioning for cast im m obili ation afte r fracture re duction in ve rte bral h pe rlordosis

a Pre paring for a spine corse t with sim ple tools se lf made h pe rlordosis table

The e ntire bod will be sagging

Sagging patie nt positioning c Corse t in h pe rlordosis d Image showing the thre e point principle at wor re sulting in the lum bar spine be ing in h pe rlordosis to allow re duction of the ve rte bral com pre ssion fracture

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

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ebhard, Pe te r ichter, astian Sche ide rer

Type of fracture

racture pattern

Nonoperati e treatment

perati e treatment ot indicated

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Wedge pattern endplate impression stable

Indicated

1

Wedge impaction stable

Indicated

1

Corpus collapse

nly in special situations

ecommended treatmentw

Sagittal split fracture stable

nly in special situations

ecommended treatment

Coronal split fracture stable

nly in special situations

ecommended treatment

Pincer fracture

nly in special situations

ecommended treatment

Incomplete burst

nly in special situations

ecommended treatment

Split burst

nly in special situations

ecommended treatment

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agerl lassi cation

Type of fracture

racture pattern

Nonoperati e treatment

perati e treatment

Complete burst

nly in special situations

ecommended treatment

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Flexion-distraction fractures

nly in special situations

ecommended treatment

B

Flexion-distraction fractures

nly in special situations

ecommended treatment

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Flexion-distraction fractures

ot indicated

ecommended treatment

otation injuries/fractures

ot indicated

ecommended treatment

otation injuries/fractures

ot indicated

ecommended treatment

otation injuries/fractures

ot indicated

ecommended treatment

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Ta le 3 3 Ove rvie w of various t pe s of fracture s according to the Mage rl AO Classi cation of thoracic and lum bar spine fracture s, and the available tre atm e nt options

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

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• Trau m atic ru ptu res o in tervertebral discs are in dication s or operative stabilization • I n ot displaced, isolated ractu res o th e C2 vertebral body can be treated w ith a h ard collar or sem irigid com bicast collar, in clu din g pu rely an terior ractu res o th e C2, w h ich h ave n o im pact on stability • Un stable th oracic an d lu m bar spin e ractu res m u st be treated operatively becau se o th e risk o n eu rological dam age, yet som e in ju ries can be treated n on operatively, especially stable ractu res, an d ractu res in ch ildren , on ce th e ractu re h as rst been redu ced in vertebral h yperlordosis.

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• In con trast to th e recom m en dation s m ade by Böh ler, cast im m obilization is rarely u sed or spin e ractu res in developed cou n tries, yet w h en n on operative treatm en t o spin e in ju ries is in dicated, cu stom -m ade in dividu ally adju sted or rem ovable corsets an d orth oses can be u sed • In special situ ation s, as w ell as in developin g cou n tries, corsets are a valid altern ative to operative treatm en t • In th e cervical spin e, depen din g on th e stability level, treatm en t option s ran ge rom im m obilization by cervical collars an d braces, to h alo, Min erva, or Diadem casts/ orth oses, w ith stern al-occipital-m an dibu lar type im m obilizers bein g th e m ost e ective in lim itin g th e u pper cervical spin e m otion o n on h alo devices

e fe re n ce s

1. B le r . [The Treatment of Fractures]. Vol 1 an d 2. 9th –11th ed. Vien n a: Wilh elm Mau drich ; 1943. Germ an . 2. o n s o n , a rt , Sim m o n s , et a l . Cervical orth oses. A stu dy com parin g th eir e ectiven ess in restrictin g cervical m otion in n orm al su bjects. J Bone Joint Surg Am. 1977 Apr; 59(3):332–339. 3. vo ra , Sc n e id e r , Sa ld in ge r P, e t a l . Biom ech an ics o th e cran iocervical region : th e alar an d tran sverse ligam en ts. J Orthop Res. 1988; 6(3):452 – 461. 4. a a rla , C a n g S , T e o d o re N, e t a l . Atlas ractu res. Neurosurgery. 2010 Mar; 66(3 Su ppl):60 –67. 5. ic m a n C , re e n e , So n n t a g . In ju ries in volvin g th e tran sverse atlan tal ligam en t: classi cation an d treatm en t gu idelin es based u pon experien ce w ith 39 in ju ries. Neurosurgery. 1996 Jan ; 38(1):4 4 –50. 6. a d le N, ic m a n C , Bro n e r C , e t a l . Acu te trau m atic atlas ractu res: m an agem en t an d lon g term ou tcom e. Neurosurgery. 1988 Ju l; 23(1):31–35. 7. e vin e , d a rd s CC. Fractu res o th e atlas. J Bone Joint Surg Am. 1991 Ju n ; 73(5):680 –691. 8. Se ga l S, rim m , St a u ffe r S . Non -u n ion o ractu res o th e atlas. J Bone Joint Surg Am. 1987 Dec; 69(9):1423 –1434. 9. e n a ro , Pa p a lia , i a r t in o , e t a l . Th e best su rgical treatm en t or type II ractu res o th e den s is still con troversial. Clin Orthop Relat Res. 2011 Mar; 469(3):742 –750.

10.

n d e rs o n

,

lo n o

T. Fractu res o

th e odon toid process o th e ax is. J Bone Joint Surg Am.1974 Dec; 56(8):1663 – 1674. 11. lle r , Sc in n e n I, is c e r , e t a l . Non -rigid im m obilisation o odon toid ractu res. Eur Spine J. 2003 Oct; 12(5):522–525. 12. No u r a s , S i , a n n e m re d d P, e t a l . Operative versu s n on operative m an agem en t o acu te odon toid Type II ractu res: a m eta-an alysis. J Neurosurg Spine. 2009 Dec; 11(6):651–658. 13. Se o ld , Ba le C. Fu n ction al ou tcom e o su rgically an d con servatively m an aged den s ractu res. Spine (Ph ila Pa 1976). 1998 Sep; 23(17):1837–18 45. 14. e n n a rs o n P , o s t a fa vi , Tra n e lis C, e t a l . Man agem en t o type II den s ractu res: a case-con trol stu dy. Spine (Ph ila Pa 1976). 2000 May; 25(10):1234 –1237. 15. Ta s ia n , a e rci S, Bif , e t a l. Halo-vest im m obilization in creases early m orbidity an d m ortality in elderly odon toid ractu res. J Trauma. 2006 Jan ; 60(1):199 –203. 16. a n , e n d e rs o n . Th e epidem iology o ractu res an d ractu red islocation s o th e cer vical spin e. Injury. 1992; 23(1):38 –4 0. 17. ffe n d i B, o , Co rn is B, e t a l . Fractu res o th e rin g o th e ax is. A classi cation based on th e an alysis o 131 cases. J Bone Joint Surg Br. 1981; 63-B(3):319 –327.

, d a rd s CC. Th e 18. e vin e m an agem en t o trau m atic spon dylolisth esis o th e ax is. J Bone Joint Surg Am. 1985 Feb; 67(2):217–226. 19. Be n e l C, a rt B , Ba ll P , e t a l . Fractu res o th e C-2 vertebral body. J Neurosurg. 1994 Au g; 81(2):206 –212. 20. ia lle , , Sc m id e r , e va s s o r N, e t a l . [ Exten sion tear-d rop ractu re o th e ax is: a su rgically treated case]. Rev Chir Orthop Reparatrice Appar Mot. 200 4 Apr; 90(2):152–155. Fren ch . 21. im , e e , im C. Treatm en t ou tcom e o cer vical tear drop ractu re. A sian Spine J. 2009 Dec; 3(2):73 –79. 22. St a n n a rd P, Sc m id t , re go r P e d s . In ju ries to th e cer vicocran iu m . Surgical Treatment of Orthopaedic Trauma. 1st ed. New York: Th iem e Med ical Pu blish ers; 2007:101–137. 23. e i , a ge rl . Classi cation o in ju ries o th e th oracic an d lu m bar spin e. Aebi M, Arlet V, Webb J K (eds). AO Spine Manual. Vol 2. Stu ttgart, New York: Th iem e Medical Pu blish ers; 2007:41–75

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Author Thomas Neubauer

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Pediatric fractures In t ro d u ct io n

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Ad va n t a ge s p e d ia t ric b o n e s h a ve co m p a re d w it h a d u lt b o n e s

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Dis a d va n t a ge s p e d ia t ric b o n e s h a ve co m p a re d w it h a d u lt b o n e s

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Sp o n t a n e o u s co rre ct io n a n d re m o d e lin g o f b o n e s

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Co n t ra in d ica t io n s fo r n o n o p e ra t ive t re a t m e n t

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No n o p e ra t ive t re a t m e n t Proxim al hum e rus um e rus, shaft Distal hum e rus adial he ad ore arm , m iddle and proxim al third Distal fore arm Proxim al fe m ur e m ur, shaft Distal fe m ur supracond lar Proxim al tibia Tibia, shaft Distal tibia m e taph sis

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Wh ich t yp e s o f in ju r y s h o u ld a lw a ys b e o p e ra t e d ?

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Evid e n ce a n d re s e a rch

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Op e ra t ive a n d n o n o p e ra t ive t re a t m e n t in co m p le m e n t

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Va ria t io n s in t re a t m e n t—t h e in flu e n ce o f e n viro n m e n t a l, ge o gra p h ic, a n d s o cio e co n o m ic fa ct o rs in in d u s t ria lize d ve rs u s d e ve lo p in g e co n o m ie s

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Su m m a r y

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Re fe re n ce s

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Author Thomas Neubauer

Alth ou gh th e n u m ber o in dication s or su rgical xation o pediatric ractu res h as in creased over recen t decades, today, m ore th an 90% o all pediatric ractu res in in du strialized cou n tries are still treated n on operatively [1]. Th e skills o n on operative treatm en t are still requ ired in order to per orm basic th erapy i su rgical th erapy can n ot be applied. Th ere ore, a th orou gh kn ow ledge o closed ractu re redu ction an d im m obilization tech n iqu es, as w ell as th eir in dication s, represen ts a prerequ isite or th e treatm en t o th e vast m ajority o ch ildren ’s ractu res.

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Ad va n t a ge s p e d ia t ric b o n e s h a ve co m p a re d w it h a d u lt b o n e s

Th e h ealin g properties o pediatric bon es h ave a n u m ber o speci c advan tages n ot ou n d in adu lts, m akin g n on operative treatm en t su itable or th e m ajority o ractu res in th is age grou p. Th ese in clu de: • Callu s orm ation is m ore exten sive • Callu s orm ation is qu icker an d m ore reliable • Callu s is qu ickly degraded • Spon tan eou s correction o prim ary m alalign m en t occu rs by grow th • Th e con dition o local so t tissu es an d vascu larity is u su ally optim al • Persistin g de cits as a resu lt o im m obilization are rare.

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Despite th e qu icker an d m ore reliable h ealin g properties o you n g bon es, th ere are, h ow ever, a n u m ber o disadvan tages th at n eed to be con sidered. Th ese in clu de: • Du e to h u m an grow th , a su rgeon h as to deal w ith variou s skeletal developm en tal stages. Th is requ ires a sou n d kn ow ledge o th e adequ ate th erapy or each speci c age grou p. Th e poten tial or spon tan eou s correction m u st be calcu lated in dividu ally or every ractu re in respect to location , grow th poten tial, an d corrective m ech an ism s • Posttrau m atic m ech an ism s can som etim es cau se grow th distu rban ces an d aggravate in to prim ary posttrau m atic m alalign m en t, a ph en om en on th at can occu r in depen den tly o th e ch osen th erapy or th e qu ality o treatm en t • Du e to th e rapid callu s orm ation in pediatric bon es, th ere is a sh orter tim e ram e or an y su ccess u l ch an ge in th erapy • In you n ger ch ildren , cooperation betw een patien t an d doctor m ay be restricted, an d com m u n ication can som etim es becom e m ore com plex as paren ts h ave to be in clu ded in to th e decision m akin g process.

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Th e reason th at m ost pediatric ractu res can be treated n on operatively is based on th e m ost im pressive advan tage o th e grow in g skeleton , n am ely th e spon tan eou s correction o posttrau m atic m alalign m en t by grow th . Th e reliability o th is rem odelin g ph en om en on depen ds on several param eters [2]: • Th e location : Usu ally th e osteogen ic capacity in th e m etaph yseal area is m ore pron ou n ced th an in th e diaph ysis. In particu lar, th e con tribu tion o th e n eigh borin g ph ysis to grow th , w h ich is gen etically determ in ed, h as a great in f u en ce on correction . In th e u pper extrem ity, th e periph eral ph yses (proxim al h u m eru s, distal radiu s) con tribu te con siderably to th e grow th o th e bon es (u su ally 80% ) (see Fig 9 .4 -1 ). In con trast, th is pattern di ers com pletely in th e low er extrem ity, as h ere th e cen tral ph yses con tribu te 80% an d th e periph eral 20% to grow th • Th e age o th e patien t: In gen eral, th e corrective poten tial dim in ish es con tin u ou sly rom th e age o 10–12 years on w ards an d on ly m in or axial deviation s can be tolerated • Th e ractu re plan e: Gen erally a u n iplan ar m alalign m en t can be corrected m ore easily th an a m u ltiplan ar on e. Malalign m en t situ ated in th e plan e o u n ction (eg, sagittal m alalign m en t in n gers) is also corrected m ore easily by grow th th an th ose w ith an orien tation perpen dicu lar to th at plan e • Th e n u m ber o in terven tion s: Repeated in terven tion s can cau se grow th distu rban ces an d, th ere ore, all in vasive in terven tion s as w ell as m an ipu lation s sh ou ld be kept to a m in im u m .

Di erin g resu lts are to be expected in regard to spon tan eou s correction in di eren t location s depen din g on th e a ected bon e/ epiph ysis, age o th e patien t, an d speci c orien tation o th e m alalign m en t. Th e local m ech an ism s o bon e rem odelin g are varied an d in clu de speci c eatu res as w ell as com pletely u n speci c processes in w h ich correction occu rs by ch an ce th rou gh ph ysiological grow th m ech an ism s. Th ese in clu de: • Fractu re an gu lation s: An gu lation s are corrected by th e ph ysis th rou gh asym m etric grow th as, accordin g to Pau w els, th e ph ysis n ext to a ractu re h as th e disposition to orien tate itsel perpen dicu lar to th e in com in g orces [3]. Diaph yseal ractu re an gu lation s are corrected by bon e apposition on to th e con cave side o th e bon e, w h ile on th e con vex side (ten sion side) bon e is absorbed in accordan ce w ith th e law o cortical dri t (w h ere bon es adapt in respon se to stress/ orce) • Posttrau m atic overgrow th : It is w ell kn ow n th at in creased grow th activity occu rs a ter trau m a, w h ose e ect is m ore dram atic in th e low er extrem ity. Fem oral overgrow th is in depen den t o th e ractu re level w ith in th e bon e, age, an d position o ractu re du rin g h ealin g; it ach ieves 0.9 cm on average [4]. In con trast, tibial overgrow th is age depen den t an d less pron ou n ced. How ever, on e th eory su ggests th at posttrau m atic h yperem ia o a bon e an d its ph yses in itiates variou s m ech an ism s th at a ect bon e len gth progn osis. Th u s, prolon ged h yperem ia (ie, by in ten se bon e rem odelin g) produ ces in creased len gth w h en ever th ere is a w ide open ph ysis n earby. On th e oth er h an d, a paradoxical sh orten in g o th e bon e m ay occu r in older ch ildren as th e in creased activity con tribu tes to early ph yseal closu re • An teversion : Ph ysiological m ech an ism s su ch as th e developm en t o em oral n eck an teversion m ay sh ow som e in f u en ce on a rotation al m alalign m en t.

Fig 9 .4 -1 Distal radial fracture in a oung patie nt, with nonope ra tive tre atm e nt in a plaste r cast e m ode ling le ads to re building and anatom ical change

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Author Thomas Neubauer

Region

Forearm proximal

Duration on a erage

perati e treatment

Gilchrist Velpeau

3–4 weeks

-wires

Side to side: shaft width Shortening: 1 cm Sagittal/frontal: 10°

Gilchrist Velpeau (brace after 2 weeks)

4 weeks

SI 1 (external fixator (I 2)

Sagittal: 7 years: 20° 7 years: none Frontal: none otation: none

Collar and cuff: Above-elbow cast

4 weeks

-wires SI 1 (external fixator)

12 years 40°

Humerus shaft

Humerus distal

Nonoperati e treatment

Supracondylar:

adial condyle:

one

Above-elbow cast

4–5 weeks

-wires Cannulated screws Plates (adolescents)

Ulnar epicondyle:

one

Above-elbow cast

4 weeks

-wires Cannulated screws

5 years: 60° 1/2 shaft width 10 years: 40° 1/3 shaft width 14 years: 20° 14 years: 10°

Above-elbow cast

4 weeks

adial head:

lecranon:

Frontal: none otation: none Sagittal: -10°

Above-elbow cast

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ccepted displacement for nonoperati e treatment age dependent Humerus proximal

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Non operative treatm en t o pediatric ractu res, in addition to plaster o Paris an d syn th etic casts, in clu des a ran ge o pre abricated an d cu stom -m ade ban dages an d devices. How ever, plaster o Paris (POP) casts cover th e m ajority o in dication s as it is alw ays available, can be easily applied an d con tou red to th e body su r ace, an d is n eith er toxic n or in f am m able (ch apter 6 Properties o cast m aterials). Du e to th e qu ick availability, low cost, an d ew con train dication s or its application , POP is still th e w orkin g h orse in th e treatm en t o pediatric ractu res arou n d th e w orld (ch apter 7 Socioecon om ic con sideration s). Oth er option s or th e n on operative treatm en t o pediatric ractu res in clu de sem irigid syn th etic casts or tapes, ban dages, an d orth oses.

Gen erally, all articu lar ractu res w ith ou t prim ary or secon dary displacem en t (gap < 2 m m , step-o < 2 m m ), an d w ellredu ced join t dislocation s w ith ou t addition al in traarticu lar path ology, are eligible or n on operative treatm en t.

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-wires Tension-band wiring Screws

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ccepted displacement for nonoperati e treatment age dependent

Nonoperati e treatment

Duration on a erage

Forearm shaft (proximal and middle third)

Frontal and sagittal: 5 years: -15° 5 years: -10° otation: none

Above-elbow cast

4–5 weeks

SI 1 (plate: if SI 1 is contraindicated)

Forearm distal

12 years: angulations up to 30° Side to side: shaft width 12yrs: angulations: 10 20° Side to side: ¼ shaft width

Above-elbow cast (both bones) elow-elbow cast (one bone)

3–4 weeks

-wires ( xternal fixator plate: diaphyseal/metaphyseal transition one)

Proximal femur

≤ 3 years: none

Hip spica cast

4–6 weeks

-wires Screws

Femur shaft

3 years: side-to-side: full diameter Shortening: 1 2 cm Varus: 20° Valgus: 10° Antecurvation: 10° otation: 20°

verhead extension ( 15 kg) Hip spica cast

2 weeks

SI 1 (external fixator) Adolescent nail

3 years 10 years: side-to-side: half diameter Sagittal/frontal: none otation: 20°

verhead extension ( 15 kg) Hip spica cast

4 weeks/ 2 weeks after overhead extension

Side-to-side: ¼ width Sagittal/frontal: none otation: none

Long leg cast

4 weeks

-wires Screws xternal fixator

perati e treatment

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one

Long leg cast

4 weeks

-wires Cerclage wire Screws

Tibia proximal

one

Long leg cast

4 weeks

-wires xternal fixator Plate

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Author Thomas Neubauer

4–5 weeks

SI 1 Plate xternal fixator

Short leg cast (long leg cast in small children)

2–3 weeks

-wires xternal fixator Screws

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Duration on a erage

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Nonoperati e treatment

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Elastic stable intram e dullar nailing ESIN Intram e dullar nailing IMN Ta b le 9 .4 -1

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Co n t ra in d ica t io n s fo r n o n o p e ra t ive t re a t m e n t

Application o an im m obilizin g ban dage represen ts a closed “su rgical in terven tion ”, especially w h en com bin ed w ith redu ction m an eu vers or a ractu re. Sou rces o com plication s in clu de an in adequ ate tech n iqu e, w ron g in dication s, an d ban dages n ot adapted to age grou p. Som e n on operative tech n iqu es, like th e w edgin g o a cast (see topic 12 in ch apter 3 Prin ciples o castin g) or traction th erapy, requ ire a m eticu lou s tech n iqu e an d regu lar con trols in order to preven t com plication s. Gen erally, a closed an d circu m eren tial plaster cast sh ou ld n ot be applied a ter acu te trau m a, im m ediately postoperatively, or in situ ation s w h ere so t-tissu e sw ellin g can be expected. Circu lar ban dages can n ot adapt to an in creased com partm en t volu m e an d m ay provoke com partm en t syn drom e. Th ere ore, in acu te situ ation s, on ly a w ell-padded POP splin t or a split cast ( Fig 9 .4 -2 ) are allow ed in order to ach ieve im m obilization . From a local poin t o view , con train dication s m ay exist rom ch an ges o th e so t tissu es an d/ or skin . Allergic reaction s to ban dages an d paddin g m aterials are rare.

Fig 9 .4 -2

Pre paration of a split circular cast

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7.2

Gen erally, m ost ractu res in ch ildren can be treated n on operatively. How ever, u sin g a n on su rgical procedu re m u st resu lt in a com parable, adequ ate u n ction al an d an atom ical ou tcom e. Fractu res situ ated n ext to a w ide open an d pow er u l ph ysis, su ch as th e eccen tric ph yses o th e u pper extrem ity or th e cen tral ph yses o th e low er extrem ity, w ill sh ow m ore spon tan eou s correction capacity in respon se to posttrau m atic m alalign m en t. Th e you n ger th e ch ild, th e m ore reliably th ese m ech an ism s w ill u n ction . Deviation s in th e m ain u n ction al axis o th e body (sagittal plan e) w ill correct m ore easily.

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In th e ollow in g paragraph s w e presen t, region by region , th e treatm en t option s. 7.1

Pro xim a l h u m e ru s

Metaph yseal lesion s represen t th e m ajority o ractu res an d, u p to an age o 12 years, w ill h eal w ith excellen t correction o posttrau m atic de orm ities (< 40° an gu lation ). Th ere ore, m ost ractu res can be treated n on operatively in a Gilch rist (see ch apter 18.3 Gilch rist ban dage) or Velpeau ban dage w ith ou t prior redu ction o th e ractu re.

a

b

c

d

178

Th e m ajority o th ese ractu res occu r in adolescen ts w ith a low correction poten tial. Keepin g in m in d th at even low grade m alalign m en t can represen t a distin ct cosm etic com prom ise, it is th e cu rren t tren d to stabilize su ch ractu res operatively, especially in older pediatric patien ts. I treated n on operatively, a Gilch rist, Velpeau , or Desau lt' s ban dage can be applied (see ch apter 18.3 Gilch rist ban dage), possibly ollow ed by a Sarm ien to brace (see ch apter 15.5 Sarm ien to h u m eral brace u sin g syn th etic, com bicast tech n iqu e). 7.3

Dis t a l h u m e ru s

In su pracon dylar ractu res o th e distal h u m eru s, on ly n on displaced ractu res (grade I) or ractu res w ith u n iplan ar displacem en t (grade II) are treated n on operatively w ith an above-elbow cast (see ch apters 15.1 Lon g arm splin t u sin g plaster o Paris; 15.2 Lon g arm splin t u sin g syn th etic; 15.3 Lon g arm cast u sin g plaster o Paris; an d 15.4 Lon g arm cast u sin g syn th etic, com bicast tech n iqu e) or a collar an d cu ban dage ( Fig 9 .4 -3 an d Fig 9 .4 - 4 ) (see ch apter 18.1 Collar an d cu ban dage).

a

Fig 9 .4 -3 a – d Collar and cuff bandage treatment for a ear old bo a Exam ple of a collar and cuff bandage b Supracond lar distal hum e rus fracture the fracture gap is mar e d The patie nt, a e ar old bo , suffe re d dire ct traum a on the e lbow c X ra afte r da s of im m obili ation in a collar and cuff bandage , with good anatom ical re duction The aumann line cuts the capitu lum in the m iddle third d The consolidate d supracond lar fracture afte r we e s with good callus formation e spe ciall on the radial side

Hu m e ru s , s h a ft

b

Fig 9 .4 -4 a – b Collar and cuff bandage tre atme nt for a e ar old girl a adial e picond le fracture of a e ar old girl, with a small gap at the radial cond le ne arl visible b Two we e s late r, x ra in collar and cuff, with fracture gap visible , and callus form ation on the dorsal and radial aspe ct of the distal hum e rus

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Author Thomas Neubauer

7.4

Ra d ia l h e a d

Alth ou gh its ph ysis con tribu tes little to grow th , th ere are still excellen t correction option s at th is site. How ever, th is area also h as very delicate local vascu larity, w h ich can easily be distu rbed. Th ere ore, redu ction is accom plish ed on ly in cases o severe displacem en t an d sh ou ld be per orm ed in a closed procedu re w h en ever possible. Yet, repeated an d ru strated attem pts at closed redu ction can also dam age th e ph ysis. Th e least trau m atic m an n er or redu ction o severely displaced ractu res is by elastic stable in tram edu llary n ailin g (ESIN), w h ich requ ires n o u rth er im m obilization o th e orearm . All oth er cases requ ire tem porary im m obilization w ith a plaster cast or ban dages (see ch apters 15.1 Lon g arm splin t u sin g plaster o Paris; 15.2 Lon g arm splin t u sin g syn th etic; 15.3 Lon g arm cast u sin g plaster o Paris; an d 15.4 Lon g arm cast u sin g syn th etic, com bicast tech n iqu e) ollow ed by m obilization w ith ou t ph ysical th erapy.

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With th e m iddle an d proxim al th ird o th e orearm , on ly n on displaced an d stable redu ced ractu res are treated n on operatively in an above-elbow cast (see ch apters 15.1 Lon g arm splin t u sin g plaster o Paris; 15.2 Lon g arm splin t u sin g syn th etic; 15.3 Lon g arm cast u sin g plaster o Paris; an d 15.4 Lon g arm cast u sin g syn th etic, com bicast tech n iqu e) as th e spon tan eou s correction is very lim ited an d even sm all an gu lation s o 10° m ay cau se severe u n ction al im pairm en t. An gu lation s w ith n arrow in g o th e in terosseou s space are especially n ot acceptable. Th u s, m ost prim ary displaced ractu res at th is location are treated operatively w ith ESIN. In th e n on operative treatm en t o green stick ractu res in th is location , care m u st be taken in order to ach ieve a balan ced com pression o th e w h ole ractu re zon e du rin g redu ction . I n ot, th e con cave cortex, w h ich h as u su ally on ly been ractu red partially, w ill h eal m ore rapidly th an th e gapin g cortex on th e con vex side, cau sin g a so-called “partial n on u n ion ” w ith an in creased risk o cau sin g re ractu re [5].

d

In ractu res o th e radial con dyle, on ly n on displaced ractu res are treated n on operatively, w h ile prim ary or secon darily displaced ractu res n eed to be xed operatively ollow ed by postoperative im m obilization (see ch apters 15.1 Lon g arm splin t u sin g plaster o Paris; 15.2 Lon g arm splin t u sin g syn th etic; 15.3 Lon g arm cast u sin g plaster o Paris; an d 15.4 Lon g arm cast u sin g syn th etic, com bicast tech n iqu e).

7.5

i

More severe orm s (grade III an d IV) requ ire operative stabilization w ith K-w ires, w ith addition al postoperative im m obilization in an above-elbow cast (see ch apters 15.1 Lon g arm splin t u sin g plaster o Paris; 15.2 Lon g arm splin t u sin g syn th etic; 15.3 Lon g arm cast u sin g plaster o Paris; an d 15.4 Lon g arm cast u sin g syn th etic, com bicast tech n iqu e), a Gilch rist ban dage (see ch apter 18.3 Gilch rist ban dage), or a Desau lt' s or Velpeau ban dage or 4 w eeks.

Dis t a l fo re a rm

A very good correction capacity exists in th e distal orearm u p to th e age o 12 years, so m ost o th ese ractu res are treated n on operatively. How ever, w h ile sim ple bu ckle ractu res can be treated w ith a rem ovable POP splin t, green stick an d com plete ractu res sh ow a ten den cy or redisplacem en t an d n eed con tin u ou s radiograph ic con trols an d ch an ge o cast (see ch apters 15.1 Lon g arm splin t u sin g plaster o Paris; 15.2 Lon g arm splin t u sin g syn th etic; 15.3 Lon g arm cast u sin g plaster o Paris; 15.4 Lon g arm cast u sin g syn th etic, com bicast tech n iqu e; 15.6 Dorsopalm ar (radial) sh ort arm splin t u sin g plaster o Paris; 15.7 Dorsopalm ar (radial) sh ort arm splin t u sin g syn th etic; 15.8 Palm ar sh ort arm splin t u sin g plaster o Paris; 15.9 Palm ar sh ort arm splin t u sin g syn th etic; 15.10 Dorsal sh ort arm splin t u sin g syn th etic; 15.11 Sh ort arm cast u sin g plaster o Paris; an d 15.12 Sh ort arm cast u sin g syn th etic, com bicast tech n iqu e).

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Pro xim a l fe m u r

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Most ractu res in th is area are displaced an d represen t su rgical an d orth opedic em ergen cies. In rare cases o n on displaced proxim al em oral ractu res in older ch ildren , operative treatm en t o ers great advan tages in respect to m obilization an d th e patien t’s com ort. I n o su rgical em ergen cy acilities are available, th e im m obilization in a h ip spica or an overh ead exten sion m ay be th e on ly option a ter redu ction ( Fig 9 .4 -5 ). 7.8

Fe m u r, s h a ft

Pro xim a l t ib ia

Th ere is a ten den cy or valgu s deviation to occu r in m etaph yseal ractu res o th e proxim al tibia, w h ich is detectable as a grow in g gape at th e m edial cortex. Norm ally, a cast is applied (see ch apters 16.3 Cylin der lon g leg cast u sin g syn th etic, com bicast tech n iqu e; 16.5 Dorsal lon g leg splin t u sin g plaster o Paris; 16.6 Lon g leg cast u sin g plaster o Paris; an d 16.7 Lon g leg cast u sin g syn th etic, com bicast tech n iqu e). Norm al axial align m en t can be restored w ith redu ction or w edgin g o th e cast in ligh t deviation (< 10°) (see topic 12 o ch apter 3 Prin ciples o castin g).

In th e sh a t o th e em u r, spon tan eou s correction s o axial deviation s can be expected—even th e capacity or som e com pen sation o rotation al de orm ities by grow th h as been n oted. How ever, rem odelin g m ech an ism s m ay also cau se grow th distu rban ces resu ltin g in leg-len gth discrepan cies. Th is ph en om en on sh ou ld be con sidered in all displaced ractu res an d, pre erably, th ese sh ou ld be redu ced an d stabilized by osteosyn th esis in order to allow m obilization an d w eigh t bearin g. Th eoretically, em oral ractu res can be treated in a Pavlik h arn ess (age u p to 6 m on th s), by overh ead traction o th e h ips at 90° (age u p to 2 m axim ally 3 years; < 9.1 kg), or by a h ip spica cast ( Fig 9 .4 -5 ) (see ch apters 16.1 On e-an da-h al leg h ip spica cast u sin g plaster o Paris; an d 16.2 Sin gle leg h ip spica cast u sin g syn th etic, com bicast tech n iqu e). a

Treatm en t algorith m s di er w idely accordin g to geograph ic location . In som e cou n tries, em oral sh a t ractu res are treated w ith in itial overh ead exten sion or 2 w eeks ollow ed by a h ip spica cast on ly in in an cy (see ch apters 16.1 On ean d-a-h al leg h ip spica cast u sin g plaster o Paris; an d 16.2 Sin gle leg h ip spica cast u sin g syn th etic, com bicast tech n iqu e), becau se w ith older ch ildren , n on operative treatm en t is associated w ith variou s so t-tissu e problem s an d less reliable realign m en t. 7.9

Dis t a l fe m u r (s u p ra co n d yla r)

b

Most ractu res o th e distal em u r are displaced an d requ ire redu ction . No deviation s are to be accepted, becau se a h igh rate o secon dary m alalign m en t an d grow th distu rban ce can be expected. Th u s, redu ced ractu res sh ou ld be im m obilized by K-w ires or screw s, w h ich are addition ally protected by a lon g leg cast (see ch apters 16.5 Dorsal lon g leg splin t u sin g plaster o Paris; 16.6 Lon g leg cast u sin g plaster o Paris; an d 16.7 Lon g leg cast u sin g syn th etic, com bicast tech n iqu e).

c Fig 9 .4 -5 a -c

Proxim al fe m ur fracture s

a X ra of a fe mur in a pre m ature bab b Ove rhe ad e xte nsion in a pre mature bab c

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Author Thomas Neubauer

Tib ia , s h a ft 4

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Dis t a l t ib ia (m e t a p h ys is )

Spon tan eou s correction o distal tibial ractu res is lim ited to a ran ge o 10° in th e ron tal as w ell as th e sagittal plan e. In patien ts older th an 10 years, alm ost n o correction is seen . Th u s, m ost displaced ractu res are redu ced an d xed by Kw ires an d im m obilized in a sh ort leg cast (see ch apters 16.10 Dorsal sh ort leg splin t u sin g plaster o Paris; 16.11 Dorsal sh ort leg splin t u sin g syn th etic; 16.12 Sh ort leg cast u sin g rigid syn th etic; an d 16.13 Sh ort leg cast u sin g syn th etic, com bicast tech n iqu e) or lon g leg cast (see ch apters 16.5 Dorsal lon g leg splin t u sin g plaster o Paris; 16.6 Lon g leg cast u sin g plaster o Paris; an d 16.7 Lon g leg cast u sin g syn th etic, com bicast tech n iqu e), w h ile n on operative treatm en t is reserved or n on displaced cases on ly. Depen din g on th e location , a sh ort leg cast (see ch apters 16.10 Dorsal sh ort leg splin t u sin g plaster o Paris; 16.11 Dorsal sh ort leg splin t u sin g syn th etic; 16.12 Sh ort leg cast u sin g rigid syn th etic; an d 16.13 Sh ort leg cast u sin g syn th etic, com bicast tech n iqu e) or a lon g leg cast is u sed (see ch apters 16.5 Dorsal lon g leg splin t u sin g plaster o Paris; 16.6 Lon g leg cast u sin g plaster o Paris; 16.7 Lon g leg cast u sin g syn th etic, com bicast tech n iqu e).

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Most ractu res represen t isolated ractu res o th e tibia (70% ), w h ich sh ow a ten den cy or varu s displacem en t, w h ile com plete cru ral ractu res (30% ) sh ow a ten den cy or valgu s displacem en t. Isolated tibial ractu res are eligible or n on operative treatm en t (see ch apters 16.5 Dorsal lon g leg splin t u sin g plaster o Paris; 16.6 Lon g leg cast u sin g plaster o Paris; 16.7 Lon g leg cast u sin g syn th etic, com bicast tech n iqu e; or secon darily 16.8 Sarm ien to (patella ten don bearin g) cast u sin g plaster o Paris; an d 16.9 Sarm ien to tibial brace u sin g syn th etic, com bicast tech n iqu e). A varu s ten den cy m ay be corrected by w edgin g o th e cast (see topic 12 in ch apter 3 Prin ciples o castin g), bu t care m u st be taken in order to avoid so t-tissu e lesion s ( Fig 9 .4 - 6 ). Un stable ractu res o both cru ral bon es requ ire redu ction an d stabilization by osteosyn th esis. a

b

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e Fig 9 .4 - 6 a – e An e ar old fe m ale patie nt that had sustaine d an isolate d fracture of the right tibia while s iing, and who was tre ate d with a plaste r of Paris cast a X ra controls at we e s re ve aling nonacce ptable varus displace me nt of the fragm e nts b Afte r we dging of the cast and a furthe r we e s of plaste r im m obi li ation, the m alalignm e nt was corre cte d c X ra s re ve aling an orthograde alignm e nt of the he aling fracture d–e owe ve r, afte r we dging of the cast, the patie nt com plaine d about pains be ne ath the cast for one da At cast re m oval, a circum script s in ne crosis is visible at the site of the we dge as we ll as in the are a of the m e dial malle olus

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Evid e n ce a n d re s e a rch

A ew decades ago, n early all pediatric ractu res w ere treated n on operatively w ith on ly a ew exception s o absolu te in dication s or operative treatm en t. How ever, in recen t years in in du strialized cou n tries, th e n u m ber o in dication s or operative stabilization o pediatric ractu res in creased both in absolu te as w ell as relative in dication s ( Ta b le 9 .4 -2 ). Next to th e socioecon om ic dem an ds o patien ts an d paren ts, ch ildren are con sidered “developed” at an earlier age, an d obesity is n ow a w ell-kn ow n actor n eedin g to be con sidered even in pediatric patien ts [6].

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How ever, th e decision w h eth er or n ot to operate is in f u en ced by a w ide ran ge o actors, in clu din g: • Type o ractu re • So t-tissu e dam age • Neu rovascu lar statu s • Gen eral con dition • Age • Weigh t • Bon e segm en t • Available equ ipm en t • Th e experien ce level o th e su rgeon . An overview o th e in dication s or su rgical xation o pediatric ractu res is given in Ta b le 9 .4 -2 [6]. bsolute indication

Relati e indication

pen fracture

Ipsilateral multiple fractures

eurovascular damage Severe soft-tissue compromise

ilateral fractures Floating-joint injury

Displaced intraarticular fracture

Age above 10 years

Irreducible fracture

Pathological fracture

Fu rth er stu dies in to pediatric ractu res ou n d th e ollow in g: • In bu ckle ractu res o th e orearm , rem ovable splin ts ach ieve th e sam e resu lts as plaster casts [7, 8] • Th e risk o redisplacem en t a ter distal radiu s ractu re— th e m ost requ en tly en cou n tered ractu re in ch ildh ood—is essen tially in f u en ced by th e in itial displacem en t (> 50% tran slation , > 30° axial deviation ), qu ality o redu ction , isolated radiu s ractu re versu s associated u ln a ractu re at th e sam e level, castin g tech n iqu e, as w ell as atroph y o so t tissu es du rin g im m obilization [9, 10, 11] • Di eren t in dices reveal qu ality o castin g an d redu ction in distal radiu s an d orearm ractu res: gap in dex [12], cast in dex [13], paddin g in dex [14], th ree-poin t in dex (an teroposterior an d lateral) [15] • Alth ou gh a relatively h igh rate o redisplacem en t (approxim ately 30% ) can be expected in distal radiu s ractu res treated n on operatively, prim ary pin n in g o th ese ractu res reveals n o su perior u n ction al ou tcom e [16] an d sh ow s a h igh rate o pin track in ection s, th ere ore, rou tin e pin n in g can n ot be recom m en ded [9] • Un stable ractu res o th e diam etaph yseal area o th e radiu s are problem atic an d requ ire tran sph yseal ESIN osteosyn th esis in you n ger ch ildren an d volar platin g in adolescen ts [17] • Non operative treatm en t o em oral sh a t ractu res is possible an d is m ost o ten accom plish ed in in an ts u sin g overh ead traction an d/ or a h ip spica cast. Alth ou gh n on operative treatm en t ach ieves good lon g-term u n ction al resu lts an d rem odelin g in you n ger ch ildren [18], operative th erapy provides early m obilization , a sh orter h ospital stay, an d less m alalign m en t [19].

Polytrauma Displaced femoral neck fracture Unstable forearm fracture

Ta b le 9 .4 -2

Indications for surgical xation of pe diatric fracture s

How ever, th e risk o irritatin g a local ph ysis at th e ractu re site even m ore by recu rren t m an ipu lation th an by operative in terven tion , an d th u s a ectin g th e ou tcom e, h as to be taken in to con sideration . Th ere ore, an y redu ction m an eu ver sh ou ld resu lt in a stable an d de n itive ractu re situ ation th at w ill persist u n til ractu re h ealin g h as been com pleted. I th ese goals can n ot be ach ieved by n on operative treatm en t, su rgical stabilization o th e ractu re site is th en requ ired.

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Author Thomas Neubauer

An y m an ipu lation u n der an esth esia sh ou ld be exclu sive. I a stable ractu re situ ation is n ot obtain able w ith closed redu ction , operative xation o th e ractu re sh ou ld be perorm ed im m ediately. Th is h as to be taken in to con sideration in preoperative plan n in g an d w h en in orm in g th e paren ts.

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Va ria t io n s in t re a t m e n t—t h e in flu e n ce o f e n viro n m e n t a l, ge o gra p h ic, a n d s o cio e co n o m ic fa ct o rs in in d u s t ria lize d ve rs u s d e ve lo p in g e co n o m ie s

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Alth ou gh th e prin ciples or th e treatm en t o pediatric ractu res are based on path oph ysiology, th e ch oice o treatm en t or an in dividu al type o ractu re w ill also be in f u en ced by en viron m en tal an d geograph ic actors. Th ese in clu de: • Th e in dividu al pre eren ce o th e treatin g ph ysician or a speci c m eth od • Th e tradition o teach in g in a speci c cou n try • Th e skills o treatin g person n el bein g lim ited to som e tech n iqu es on ly • Th e lim ited availability o m aterials du e to th e developm en tal an d econ om ic situ ation [20, 21].

e

As already m en tion ed, applyin g a cast or ban dage, with elective redu ction o th e ractu re, represen ts a "closed su rgical" m an ipu lation , w h ich h as to be accom plish ed w ith th e sam e plan n in g an d tech n ical th orou gh n ess as an operative procedu re. Addition ally, POP casts represen t an ideal em ergen cy tool in order to im m obilize an extrem ity an d to redu ce pain . Bu t n on operative an d operative m easu res are o ten n ot com petitive, bu t com plem en t on e an oth er, or in stan ce in m etaph yseal ractu res xed w ith K-w ires an d addition ally stabilized by a plaster cast. Th e decision betw een n on operative an d su rgical option s is essen tially in f u en ced by th e rem ain in g tim e u n til en d o grow th an d th e local correction capacity or posttrau m atic m alalign m en t. Th u s, a sou n d kn ow ledge o th e path oph ysiological prin ciples or pediatric ractu res is th e prerequ isite or su ccess u l treatm en t.

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In m ost developin g cou n tries, splin tin g o a rou gh ly redu ced lim b w ith POP w ill be practicable, w h ile su rgical treatm en t is o ten restricted to w h en in dication s su ggest th ere is a n eed to save th e extrem ity (ie, open ractu res). Even in sligh tly m ore developed cou n tries, n on operative treatm en t w ill still predom in ate, as on ly a ew people can a ord th e costs o an operation on a private basis. In m an y developin g or m oderately developed cou n tries, th e ch oice o im plan ts w ill be redu ced to extern al xators an d K-w ires, w h ich are alm ost alw ays available, an d w h ich provide a basic m eth od o stabilization . In in du strialized cou n tries, w ith th eir large variety o available im plan ts, th e in dication or operative treatm en t is n ot lim ited by a lack o resou rces. Th is is despite th e sam e in dication represen tin g a su rgically u n solvable problem in a developin g cou n try.

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• Non operative treatm en t still represen ts th e appropriate treatm en t or th e vast m ajority o pediatric patien ts • Fractu res h eal m ore rapidly in ch ildren th an in adu lts, an d th e adverse e ects o im m obilization are m in im al • Non operative ractu re treatm en t w ith plaster casts or su pport ban dages is possible in stable diaph yseal an d m etaph yseal ractu res th at are n on displaced or represen t an acceptable degree o displacem en t in respect to local rem odelin g capacity • In u n stable m etaph yseal ractu res, casts or su pport ban dages are em ployed to su pplem en t m in im al su rgical xation m eth ods (su ch as K-w ires)

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Re fe re n ce s

1. Co u r t-Bro w n CM, Ait ke n S, Ha m ilt o n TW, e t a l . Non operative ractu re treatm en t in th e m odern era. J Trauma. 2010 Sep; 69(3):699 –707. 2. Wilk in s KE. Prin ciples o ractu re rem odelin g in ch ild ren . Injury. 20 05 Feb; 36 Su ppl 1:A3 –A11. 3. Pa u w e ls F. Gesammelte Abhandlungen zur funktionellen Anatomie des Bewegungsapparates. Berlin Heidelberg New York: Sprin ger; 1965. Germ an . 4. Sh a p iro F. Fractu res o th e em oral sh a t in ch ildren . Th e overgrow th ph en om en on . Acta Orthop Scand. 1981 Dec; 52(6):649 –55. 5. Sch w a rz N, Pie n a a r S, Sch w a rz AF, e t a l . Re ractu re o th e orearm in ch ild ren . J Bone Joint Surg Br. 1996 Sep; 78(5): 74 0 –74 4. 6. Slo n go TF. Th e ch oice o treatm en t accord in g to th e type an d location o th e ractu re an d th e age o th e ch ild. Injury. 2005 Feb; 36 Su ppl 1:A12–A19. 7. Ab ra h a m A, Ha n d o ll HH, Kh a n T. In terven tion s or treatin g w rist ractu res in ch ild ren . Cochrane Database Syst Rev; 2008 16(2): CD00 4576. 8. Ke n n e d y SA, Slo b o ge a n GP, Mu lp u ri K. Does degree o im m obilization in f u en ce re ractu re rate in th e orearm bu ck le ractu re? J Pediatr Orthop B. 2010 Jan ; 19(1):77–81. 9. Ba e DS . Ped iatric d istal rad iu s an d orearm ractu res. J Hand Surg Am. 2008 Dec; 33(10):1911–1923.

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• Articu lar ractu res w ith less th an 2 m m step-o an d/ or 2 m m gap are con sidered n on displaced an d can be treated n on operatively • Traction th erapy sh ou ld be th e exception w h en ever an adequ ate operative th erapy is available; m ost o ten th e so-called overh ead traction is u sed or em u r ractu res in ch ildren below th e age o 2 years • Th e variou s approach es to treatm en t are o ten in f u en ced by region al tradition s, socioecon om ic actors, an d th e person al pre eren ce o th e su rgeon .

10. Mo n ga P, Ra gh u p a t h y A, Co u rt m a n NH . Factors a ectin g rem an ipu lation in paed iatric orearm ractu res. J Pediatr Orthop B. 2010 Mar; 19(2):181–187. 11. Za m za m MM, Kh o s h h a l KI. Displaced ractu re o th e d istal rad iu s in ch ild ren : actors respon sible or redisplacem en t a ter closed redu ction . J Bone Joint Surg Br. 20 05 Ju n ; 87(6): 8 41–843. 12. Ma lviya A, Ts in t za s D, Ma h a w a r K, e t a l . Gap in dex: a good pred ictor o ailu re o plaster cast in d istal th ird rad iu s ractu res. J Pediatr Orthop B. 20 07 Jan ; 16(1):48 –52. 13. Ch e s s DG, Hyn d m a n JC, Le a h e y JL, e t a l . Sh ort arm plaster cast or d istal ped iatric orearm ractu res. J Pediatr Orthop. 1994 Mar–Apr; 14(2):211–213. 14. Bh a t ia M, Ho u s d e n PH . Red isplacem en t o paediatr ic orearm ractu res: role o plaster m ou ld in g an d padd in g. Injury. 2006 Mar; 37(3):259 – 268. 15. Ale m d a ro ğ lu KB, Ilt a r S, Cim e n O, e t a l . Risk actors in red isplacem en t o distal rad ial ractu res in ch ildren . J Bone Joint Surg Am. 2008 Ju n ; 90(6):1224 –1230. 16. Mille r BS, Ta ylo r B, Wid m a n n RF, e t a l . Cast im m obilization versu s percu tan eou s pin xation o d isplaced d istal rad iu s ractu res in ch ildren : a prospective, ran dom ized stu dy. J Pediatr Orthop. 2005 Ju l–Au g; 25(4):490 –494.

17. Lie b e r J, So m m e rfe ld t DW. [ Diam etaph yseal orearm ractu re in ch ild h ood. Pit alls an d recom m en dation s or treatm en t]. Unfallchirurg. 2011 Apr; 114(4): 292–299. Germ an . 18. Fre ch -Dö r e r M, Ha s le r CC, Hä cke r FM . Im m ed iate h ip spica or u n stable em oral sh a t ractu res in presch ool ch ildren : still an e cien t an d e ective option . Eur J Pediatr Surg. 2010 Jan ; 20(1):18 –23. 19. Flyn n JM, Lu e d t ke LM , Ga n gle y TJ, e t a l . Com parison o titan iu m elastic n ails w ith traction an d a spica cast to treat em oral ractu res in ch ildren . J Bone Joint Surg Am. 20 04 Apr; 86-A(4):770 – 777. 20. Kirs ch TD, Be a u d re a u RW, Ho ld e r YA, e t a l . Pediatric in ju r ies presen tin g to an em ergen cy departm en t in a developin g cou n try. Pediatr Emerg Care. 1996 Dec; 12(6):411–415. 21. Ou a t t a ra O, Ko u a m e BD, Od e h o u ri TH, e t a l . [ Resu lts o treatm en t o orearm ractu res in th e ch ild]. Mali Med. 20 07; 22(3):43 –46. Fren ch .

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Author Cle mens Dumont

Soft tissue damage and defects Cleme ns Dum ont

In t ro d u ct io n ia gn o s t ics

Po s t o p e ra t ive p ro t e ct io n u n t il

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Author Cle mens Dumont

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Particu larly in blu n t trau m a, it is n ecessary to search or: • Vascu lar in ju ries [2] • Nerve in ju ries an d • Com partm en t syn drom e. In h igh -en ergy trau m as, th eir existen ce h as to be presu m ed u n til th ey h ave been exclu ded. Pen etratin g in ju ries can resu lt rom : • Cu ts • Laceration s • Stabbin g • Bites • In tru sion o a oreign body. By w ay o illu stration , in 2008, Clayton an d Cou rt-Brow n in vestigated isolated in ju ries o ten don s an d ligam en tou s in ju ries w ith ou t ractu re in th e UK. Th eir research determ in ed th at or th e u pper extrem ity, th e ollow in g in ciden ces occu rred th at year [3]: • Forearm / h an d exten sor ten don in ju ries (approxim ately 17.0% ) • Mallet n ger (approxim ately 9.0% ) • Forearm / h an d f exor ten don ru ptu re (approxim ately 4.5% ) • Uln ar collateral ligam en t in ju ry (approxim ately 3.2% ). Wh ile th is ch apter broadly explores skin an d tissu e dam age an d postoperative protection , m ore speci c details on in ju ries to th e ligam en ts an d ten don s, an d o n erves, are ou n d in ch apters 11.1 Ligam en t an d ten don in ju ries, an d 11.2 Nerve in ju ries.

Diagn ostics in so t-tissu e dam age starts w ith h istory an d in orm ation abou t th e kin d o in ju ry. A stan dardized approach is stron gly recom m en ded. Th is au th or su ggests, in order, in spection , palpation , per u sion , sen sation sen sitivity, an d u n ction . Ultrasou n d is h elp u l in cases w h ere h em atom a is su spected, an d can depict an d describe th e exten t o h em atom a as w ell as assist in visu alizin g th e h em orrh age. Fractu res are exclu ded or con rm ed by x-ray i bon y in ju ry is su ggested by h istory or exam in ation . Com pu ter tom ograph y com bin ed w ith an giograph y, i available, is a reason able tool to localize su pposed dam age to th e vascu lar system . In con trast to th ese, m agn etic reson an ce im agin g or electrom yograph y play on ly a secon dary role in acu te so t-tissu e in ju ries; th ey are seldom n ecessary.

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So ft Tis s u e Cla s s ifica t io n

Th e AO So t-Tissu e Classi cation qu an ti es so t-tissu e dam age an d con cen trates on th e criteria o closed skin lesion s (IC=in tegu m en t closed) an d open skin lesion s (IO=in tegu m en t open ). Fu rth erm ore, in accordan ce w ith th e AO So t-Tissu e Classi cation , it is possible to distin gu ish betw een m u scleten don (MT) in ju ry an d n eu rovascu lar (NV) in ju ry ( s e e Ta le ). Alth ou gh th e illu stration s dem on strate so ttissu e in ju ries o th e low er lim b, th ey can be easily tran s erred to u pper-lim b tissu e in ju ries. In th e case o severe so t-tissu e dam age, extern al xation an d stabilization is th e m eth od o ch oice in order to avoid u rth er dam age to th e so t tissu es. In tern al xation o th e u pper extrem ity is in dicated w h en ever so t-tissu e coverage is provided, or w h en f ap coverin g w ill be available w ith in a ew days. On th e oth er h an d, casts w ith w in dow s, or w ith an extern al traction device, are n ot adequ ate or th e treatm en t o open ractu res.

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So t-tissu e dam age can occu r eith er isolated or in com bin ation w ith ractu red bon e(s), an d can be su bdivided in to blu n t or pen etratin g in ju ries [1]. Clin ical experien ce sh ow s th at th ere is a ten den cy to u n derestim ate blu n t trau m a becau se, at rst glan ce, it is less strikin g w h en com pared w ith a pen etratin g in ju ry.

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pen skin lesions

uscle and tendon lesions T

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o skin lesion

Skin breakage from inside out

o muscle injury

o neurovascular injury

o skin laceration but contusion

Skin breakage from outside in 5 cm contused edges

Circumscribed muscle injury one compartment only

Isolated nerve injury

Skin breakage from outside in 5 cm increased contusion devitali ed edges

Considerable muscle injury two compartments

Locali ed vascular injury

Considerable full-thickness contusion abrasion extensive open degloving skin loss

uscle defect tendon laceration extensive muscle contusion

xtensive segmental vascular injury

Compartment syndrome with wide injury one

eurovascular injury including subtotal or even total amputation

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Author Cle mens Dumont

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Sm all de ects on th e dorsal side o th e h an d can be covered by local f aps. De ects on th e palm ar side are m ore com plicated becau se o th e rm con n ection betw een th e skin an d th e so t tissu e. Several m icrosu rgical f aps, developed in recen t years, provide m ore in dividu al an d esth etic option s. How ever, pedicled f aps are still in u se, an d th e su rgical tech n iqu e o elevatin g th e groin f ap is less dem an din g in com parison . Th e pedicled groin f ap is based on th e su percial circu m f ex iliac artery th at ru n s parallel to th e in gu in al ligam en t, ru n n in g abou t 2 cm below it.

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Overall, a lim ited postoperative protection or a sh ort period o tim e can redu ce pain an d secu re th e resu lt o th e operative th erapy (see ch apters 15.13 Th u m b spica splin t u sin g plaster o Paris; 15.14 Th u m b spica splin t u sin g syn th etic; 15.17 Dorsopalm ar (u ln ar gu tter) sh ort arm splin t in clu din g tw o or m ore n gers u sin g plaster o Paris; 15.18 Dorsopalm ar (u ln ar gu tter) sh ort arm splin t in clu din g tw o or m ore n gers u sin g syn th etic; 15.19 Palm ar sh ort arm splin t in clu din g th e n gers u sin g plaster o Paris; an d 15.20 Sh ort arm cast in clu din g tw o or m ore n gers u sin g syn th etic, com bicast tech n iqu e). Yet, depen din g on th e operative tech n iqu e, postoperative protection an d im m obilization o th u m b or n ger join ts can carry th e risk o sti n ess in th e h an d an d especially in th e operated n ger. Tw o u rth er poin ts to rem em ber are: • Du rin g th e period o im m obilization , patien ts h ave to be advised to m obilize th e u n in ju red n ger join ts, th e elbow join t, an d sh ou lder join t as ar as pain allow s • In cases o severe so t-tissu e in ju ries, an extern al xator is a reliable an d secu re su rgical treatm en t.

Th e groin f ap is a reliable an d versatile su rgical option or coverin g larger h an d de ects. Th e f ap can be selected w ith a len gth o abou t 25 cm an d it can be u sed or de ects on eith er th e dorsu m ( ig , ig , ig 3 , ig 4 ) or palm [5]. Th e pedicle is cu t w h en th e f ap h as h ealed in , n orm ally a ter 3 w eeks. Alth ou gh a lon g pedicle o th e f ap is th e aim , th e disadvan tages o u sin g th e pedicled groin f ap in clu de discom ort or th e patien t resu ltin g rom restricted m obilization o w rist, elbow , an d sh ou lder join ts, as w ell as th e im possibility o elevatin g th e h an d in order to preven t edem a. Fu rth er disadvan tages in clu de a loss o sen sitivity on th e dorsu m o th e h an d an d th e n eed or a secon d operation w h en dividin g th e f ap a ter 3 w eeks, an d perh aps a th ird operation or debu lkin g th e f ap a ter 6 m on th s. 5

e la t ive co n t ra in d ica t io n s

Th e groin f ap is n ot in dicated in patien ts th at are: • Non com plian t • Restive an d stu bborn ly im patien t • Alcoh olic or • Patien ts w ith epilepsy. In adu lt n on com plian t patien ts it is recom m en ded to u se local f aps or ree m icrosu rgical f aps in stead o th e groin f ap.

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Tem porary plaster o Paris or syn th etic splin ts are in dicated as em ergen cy im m obilization u n til th e operative treatm en t can be in itiated.

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Th e ollow in g poin ts sh ou ld alw ays be rem em bered: • Do n ot u n derestim ate so t-tissu e in ju ry, especially in th e rst ew days postin ju ry • Treat operatively th ose ractu res with open in tegum ent in order to avoid u rth er so t-tissu e dam age th at can n ot be assessed accu rately u n der a cast or splin t • Treat operatively th ose ractu res with closed in tegu m en t an d severe so t-tissu e in ju ry grade II or h igh er.

ig A e ar old m an with a contaminate d old wound on the dorsum of the hand

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ig Intraope rative picture afte r e le vating the groin ap, which will cove r the de fe ct on the dorsal side of the hand The lowe r e xtre m it m a be im m obili e d with a spe cial custom m ade cast in orde r to lim it m otion on the ap during he aling

ig 4 The e xce ptional case of a ve ntilate d pre m ature infant with a ne crotic de fe ct of the right hand e ffe ctive l tre ate d with a groin ap The custom m ade additional thoracic and uppe r le g se m irigid cast a modi cation of the m e thod de scribe d in chapte r Single le g hip spica cast using s nthe tic, com bicast te chni ue pre ve nte d dam age to the ap cause d b uncontrolle d pulling out of the pe dicle

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b ig 3a The sam e e ar old man, we e s afte r ap cove r ing and we e s afte r dividing the ap pe dicle with re stricte d func tion of the nge rs in e xte nsion a and e xion b

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Author Cle mens Dumont

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No n o p e ra t ive t re a t m e n t

Treatm en t w ith casts or splin ts, h ow ever, can be en tirely appropriate in th e ollow in g in stan ces: • Ru ptu red m u scles • Blu n t or pen etratin g tissu e in ju ries • Select distal ten don in ju ries, su ch as m allet n ger • Postoperative protection or su rgically treated ractu res • Postoperative protection or select ligam en t ru ptu res, su ch as th e u ln ar collateral ligam en t o th e th u m b • Postoperative protection or select exten sor or f exor ten don in ju ries. In d ica t io n s fo r o p e ra t ive t re a t m e n t

Absolu te in dication s or operative treatm en t are: • Sign i can t m u scle tear • So t-tissu e in ju ries w ith tran section o an artery [6] or n erve [7] • Open ractu res or lu xation s • Fractu res com bin ed w ith ligam en t an d/ or ten don in ju ries. Neverth eless, postoperative im m obilization in a cast m igh t be n ecessary in order to protect th e su tu res o ligam en ts, vessels, an d/ or n erves. It is th ere ore th en th e su rgeon ’s/ ph ysician ’s respon sibility th at all th e actors relatin g to th e type o tissu e dam age h ave been con sidered, th e com plication risks an alyzed, an d th at th e best treatm en t is im plem en ted or th e patien t. Fu rth er in orm ation on so t-tissu e m an agem en t is available rom th e AOTrau m a pu blication Manual of Soft-Tissue Management in Orthopaedic Trauma.

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At tim es, th ese poten tial or existin g com plication s, as w ell as oth er actors, in dicate or operative rath er th an n on operative treatm en t.

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In cases o ru ptu red m u scle bers, an arm cast or splin t sh ou ld be con sidered (see ch apters 15.1 Lon g arm splin t u sin g plaster o Paris; 15.2 Lon g arm splin t u sin g syn th etic; 15.3 Lon g arm cast u sin g plaster o Paris; an d 15.4 Lon g arm cast u sin g syn th etic, com bicast tech n iqu e) or a cast or splin t or th e low er lim b (see ch apters 16.10 Dorsal sh ort leg splin t u sin g plaster o Paris; 16.11 Dorsal sh ort leg splin t u sin g syn th etic; 16.12 Sh ort leg cast u sin g rigid syn th etic; an d 16.13 Sh ort leg cast u sin g syn th etic, com bicast tech n iqu e). Su ch im m obilization can redu ce th e pain th at n orm ally sh ou ld declin e w ith in th e rst 2 w eeks, at w h ich tim e th e splin t can eith er be rem oved or, on exception al occasion s, be replaced w ith a ban dage or an oth er 2 w eeks.

So t-tissu e in ju ries are correlated w ith several risks o com plication s. Depen din g on th e severity o th e dam age, th ey can resu lt in : • Serom a • Hem atom a • Com partm en t syn drom e • In ection • Necrosis.

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Ru ptu re o m u scle bers o th e u pper extrem ity is rare bu t can resu lt in pain an d h em atom a. Th e dam aged m u scle tissu e reacts w ith sw ellin g an d edem a. Du e to th e restriction o th e m u scle- ascia system , th e m u scle can n ot exten d. In th e case o pressu re bu ildu p w ith in th e m u scle bers, th e com partm en t pressu re can in crease to su ch a degree th at it m ay even cau se com partm en t syn drom e.

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• So t-tissu e dam age, eith er isolated or com bin ed w ith ractu res, in clu des blu n t an d pen etratin g types o in ju ries, yet th ere is a ten den cy to u n derestim ate blu n t trau m a as it is n ot as obviou s as a pen etratin g in ju ry • Extern al xation sh ou ld be con sidered in cases o severe so t-tissu e dam age, bu t in tern al xation o th e u pper extrem ity is in dicated w h en ever so ttissu e coverage is provided • Th e u se o a cast can provide postoperative protection u n til w ou n d h ealin g, as illu strated by th e exam ple o a groin f ap in a you n g ch ild • Operative rath er th an n on operative treatm en t is requ ired in cases o tissu e dam age w ith tran section o an artery or n erve, open ractu res or lu xation s, or ractu res com bin ed w ith ligam en t an d ten don in ju ries especially th ose th at requ ire su rgical repair to restore u n ction .

e fe re n ce s 1.

. Blu n t trau m a. Volgas DA, Harder Y (eds). Manual of Soft-Tissue Management in Orthopaedic Trauma. Stu ttgart New York: Georg Th iem e Verlag; 2011:28 –39.

2.

o c i S, Tre m la N, e licia n o e t a l . Blu n t vascu lar trau m a in th e

3.

4.

5. 6.

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extrem ity: d iagn osis, m an agem en t, an d ou tcom e. J Trauma. 2003 Nov; 55(5):814 –824. Cla t o n , Co u rt Bro n C . Th e epidem iology o mu scu loskeletal ten din ou s an d ligam en tou s in ju ries. Injury. 2008 Dec; 39(12):1338 –134 4. o lga s . Classi cation system s. Volgas DA, Harder Y (eds). Manual of Soft-Tissue Management in Orthopaedic Trauma. Stu ttgart New York: Georg Th iem e Verlag; 2011:66 –69. c re go r I , a c s o n IT. Th e groin f ap. Br J Plast Surg. 1972 Jan ; 25(1):3 –16. ra n , S tta C , S a , e t a l. A ve-year review o m an agem en t o u pper-ex trem ity arterial in ju ries at an u rban Level I trau m a cen ter. Ann Vasc Surg. 2012 Ju l; 26(5):655 –66 4.

7. Sin is N, ra u s , Pa p a gia n n o u lis N, e t a l . Con cepts an d developm en ts in periph eral n erve su rger y. Clin Neuropathol. 2009 Ju l–Au g; 28(4):247– 262.

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Author Kame l A

igament and tendon in uries Kamel A

In t ro d u ct io n

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e s t , Ice , Co m p re s s io n , a n d

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Author Kame l A

Closer assessm en t reveals th at in spite o th eir sim ilarities, both o th ese tissu es are per ectly adapted to su it th eir speci c u n ction : • Ligam en ts are an essen tial com pon en t o join ts, providin g or con strain ed u n ction al m otion • Ten don s are part o a m u scle, an d are respon sible or tran sm ittin g m u scle con tractile orce to an appropriate location .

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Ligam en ts an d ten don s are th e body’s essen tial u n ction al con n ective tissu es. Th eir appearan ce is o ten sim ilar, w ith stou t, den se, h igh ly organ ized collagen bers. Both are relatively avascu lar, f exible, an d specialized or ten sile load bearin g. Th eir relative sti n ess in ten sion allow s th em to absorb an d tran sm it orces w ith ou t excessive stretch in g. Th is perm its ligam en ts to resist u n desirable join t m otion , an d allow s m u scu lar con traction on a ten don to pu ll on a distan t bon e, an d m ove or stabilize a join t, an d th u s to participate in u n ction al activities. Th e f exibility an d glidin g properties o ligam en ts an d ten don s m in im ize th eir in ter eren ce to desired m otion .

Ligam en ts an d ten don s h ave to m eet several m ech an ical requ irem en ts to u l ll th eir u n ction al roles satis actorily. In addition to stren gth , th ey m u st possess appropriate len gth , su cien t sti n ess, an d reedom rom adh esion s th at restrict desirable join t m otion . A ligam en t th at h as been partially torn an d stretch ed beyon d its correct len gth m ay be u n able to keep its join t align ed u n der load. Th e sam e is tru e w h en th e ligam en t’s elasticity h as in creased, so th at it stretch es an d allow s an gu lar m otion an d loss o join t su r ace con tact. I an in ju red ligam en t h as developed scarrin g an d adh esion s at th e su rrou n din g tissu es, join t m otion m igh t be restricted, preven tin g desired activities.

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Proper assessm en t an d care o ligam en t an d ten don in ju ries requ ires detailed kn ow ledge o local an atom y as w ell as region ally speci c path ology, in clu din g sym ptom s, sign s, ph ysical exam in ation , an d th e spectru m o trau m atic an d oth er con dition s th at in volve th e region o con cern . Th is ch apter o ers a gen eral overview o ligam en t an d ten don in ju ries, an d in clu des select exam ples to h elp illu strate th e im portan t role played by casts, splin ts, an d su pport ban dages in th e care o con n ective tissu e in ju ries.

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E ective diagn osis o ligam en t an d ten don in ju ries depen ds sign i can tly u pon kn ow ledgeable h istory an d ph ysical exam in ation . Im agin g stu dies (x-rays, MRIs, an d/ or u ltrason ograph y) play a m ore su bsidiary role, bu t can be very h elp u l in selected in ju ry types. Th e exam in er m u st con sider th e details o th e in ju ry, in clu din g possible prior even ts. Also im portan t is th e iden ti cation o th e severity an d tim in g o an y u n ction al de cits a ter th e in ju ry – cou ld activity be con tin u ed, an d i so w ith w h at i an y lim itation s an d/ or pain . I sign i can t tim e h as elapsed a ter th e in ju ry, w h at, i an y, recovery or deterioration h as occu rred?

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Local pain in th e region o a join t or m u scle-ten don u n it an d im paired u n ction o th e part are typical o both ligam en t an d ten don in ju ries. It m u st be rem em bered, h ow ever, th at oth er stru ctu res in th e region m igh t be th e prim ary or associated sou rce o pain , an d th ese sh ou ld be con sidered as w ell. Bon y ten dern ess sh ou ld su ggest a ractu re, in clu din g a grow th plate in ju ry in skeletally im m atu re patien ts. A join t e u sion or h em arth rosis m ay represen t in tern al deran gem en t (torn m en iscu s or labru m , a torn in traarticu lar ligam en t, or an osteoch on dral ractu re). Bu rsitis, periten din itis, or in trin sic ten don in f am m ation (ten din itis) m igh t resu lt rom an acu te in ju ry or a gradu ally developin g process. Assu m in g th at a pain u l join t or m u scle is sim ply a m in or sprain or strain can be a pit all th at delays diagn osis o a m ore seriou s con dition . Th ere ore, pain th at in creases, an d/ or ails to im prove w ith rest an d sim ple m odalities, sh ou ld alw ays su ggest th e n eed or th e reassessm en t o a pain u l extrem ity. Regardin g exam in ation , th e cru cial issu es are: • Localization o pain an d/ or ten dern ess (an d sw ellin g) • Assessm en t an d gradin g o join t in stability • Stren gth assessm en t o each m u scle-ten don u n it in th e in volved area • Neu rologic assessm en t (m otor an d sen sation ) • Periph eral arterial pu lses distal to th e in volved area(s). In alm ost all cases o ligam en t or ten don in ju ry, th is th orou gh assessm en t, gu ided by am iliarity w ith th e typical region al in ju ries, w ill be su cien t or a reliable diagn osis, based u pon h istory an d ph ysical exam in ation . Com plete ligam en t ru ptu res alm ost alw ays produ ce gross join t in stability. Stress applied to a com pletely ru ptu red ligam en t (eg, in version stress to an an kle w ith lateral collateral ligam en t ru ptu re) resu lts in sign i can t varu s tilt an d little i an y eviden t resistan ce. How ever, m u scu lar con traction an d/ or in tact secon dary restrain t ligam en ts can obscu re th is n din g.

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Ligam en t an d ten don in ju ries are com m on in u pper an d low er extrem ities. In act, th ey accou n t or 30 to 50% o all in ju ries related to sports activities [1]. Ligam en t an d ten don in ju ries can be cau sed by direct or in direct orces, w ith eith er open or closed w ou n ds, som etim es w ith associated local in ju ries. Man y are du e to a sin gle trau m atic episode, bu t som e are related to repetitive u se, an d/ or preexistin g in f am m atory or degen erative ch an ges. Tissu e disru ption occu rs in tw o orm s: • Partial disru ption , as is typical w ith less-severe in ju ries, bu t w h ich are m ore com m on • Com plete (or total) disru ption , resu ltin g rom extern al laceration s, or rom ten sile overload th at exceeds th e ailu re stren gth o th e in ju red stru ctu re. Recogn ition o totally disru pted ligam en ts an d ten don s is im portan t as su ch in ju ries o ten requ ire su rgical treatm en t. On th e oth er h an d, m ost partial ru ptu res o ligam en ts an d ten don s (or m u scles) w ill h eal satis actorily w ith m ech an ical protection an d reh abilitative exercises. Un less an obviou s in dication or su rgical treatm en t is presen t, a trial o n on operative m an agem en t is appropriate or m ost patien ts. Su rgery can be de erred u n til it becom es clear th at a satisactory recovery w ill n ot be ach ieved w ith ou t it. In ju red ligam en ts an d ten don s ben e t rom m ech an ical protection rom casts, splin ts, or oth er su pportive devices becau se partial disru ption s w eaken th ese tissu es, placin g th em at risk o com plete ru ptu re i sign i can t loadin g occu rs be ore slow ly progressive h ealin g h as restored en ou gh stren gth to w ith stan d th e levels o orce n eeded or a relatively seden tary li estyle, n ot to m en tion ath letic or risk activities. Rein ju ry, in clu din g com plete ailu re, is a w ellkn ow n com plication a ter su rgical repair o ligam en ts or ten don s, so th at im m obilization an d su pport are o ten essen tial parts o postoperative m an agem en t. Addition ally, m otion an d loadin g w ith in tolerated lim its actu ally prom otes th e h ealin g process, an d as w ith bon es, th e tech n iqu es o im m obilization an d protection can take advan tage o u n ction al reh abilitation – m otion an d u se w ith in sa e lim its.

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Author Kame l A

Ligam en t in ju ries are called sprain s. Th ey are typically classi ed in to th ree grades o severity: • Grade I or m ild sprain • Grade II or m oderate sprain • Grade III or severe sprain . A grade I or m ild sprain h as m in im al stru ctu ral dam age, bu t th ere is som e ocal h em orrh age, in f am m ation , an d pain w ith loadin g. A grade II or m oderate sprain in volves partial stru ctu ral tearin g, w h ich resu lts in som e m ech an ical laxity, bu t th ere is a rm en dpoin t to passive stretch in g du rin g ph ysical exam in ation . Grade III sprain s are severe sprain s w ith com plete ligam en t disru ption , con rm able by th e absen ce o an en dpoin t to stretch in g. In adu lts, ligam en ts typically ail w ith in th eir m idsu bstan ce, w h ile avu lsion rom bon e is m ore com m on in ch ildren .

Th e term strain h as lon g been com m on ly u sed to re er to m u scle in ju ries, an d is som etim es exten ded to ten don in ju ries as w ell, h ow ever, th is broad term lacks precision . It is o ten u sed or m u scu lar an d or ten din ou s pain resu ltin g rom overu se, atigu e, an d/ or in f am m ation o m u scles, ten don s, an d su rrou n din g tissu es su ch as ten don sh eath s or bu rsas. A recen t sports m edicin e con sen su s statem en t [2] recom m en ded a m ore precise ran ge o term s to classi y m u scle an d ten don in ju ries, by separatin g th em in to th e ollow in g tw o types: • Fu n ction al m u scle disorders, w ith ou t m acroscopic tissu e disru ption • Stru ctu ral m u scle in ju ries, re erred to as m u scle tears, an d classi ed as eith er partial or total. Fu n ction al m u scle disorders, alon g w ith m in or partial m u scle tears an d ten din itis, are very com m on problem s, especially in sports m edicin e. Rest, an tiin f am m atory m easu res, an d com pressive ban dages are o ten recom m en ded or th eir treatm en t (see topic 9 RICE regim en ). As acu te sym ptom s resolve, reh abilitative exercises o ten becom e valu able, an d im m obilization with a cast or splin t is less requ en tly requ ired.

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Ten don s are cord-like collagen ou s stru ctu res th at cross on e or m ore join ts to con n ect th e con tractile tissu e o a m u scle to a discrete in sertion site o a bon e. Th ey tran s er m u scu lar orce to th e bon e to produ ce or resist join t m otion . Ten don tissu e is h igh ly organ ized, w ith h ierarch ical bu n dles o collagen , orien ted to th e ten sile orces applied to th e ten don . Tw o ch aracteristic ten don types sh ou ld be distin gu ish ed. Th ose covered w ith paraten on , su ch as th e h am strin gs, Ach illes, or patellar ten don s, h ave a better blood su pply, tran sm itted via th eir paraten on , an d h eal m ore e ectively. Th ose th at lie w ith in sh eath s, like th e n ger f exors, h ave a poorer blood su pply, receivin g n ou rish m en t in som e areas on ly by di u sion . Ten don s h ave m ore abu n dan t an d m ore organ ized collagen th an ligam en ts, an d are less viscoelastic. Th ey con tain spin dle-sh aped broblasts, w h ich play m ajor roles in ten don h ealin g. Like ligam en ts, th eir in n ervation is sign i can t an d con tribu tes essen tial proprioceptive eedback.

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Ligam en ts are prim arily collagen ou s tissu es th at con n ect th e tw o bon es o a join t. Becau se o th eir an atom ic location s an d m ech an ical ch aracteristics, th ey lim it som e types o m otion w h ile perm ittin g oth ers, th u s determ in in g each join t’s n orm al ran ge o passive m otion , in clu din g its ch aracteristically stable lim its. Ligam en ts are w ell in n ervated, an d provide im portan t proprioceptive in pu t. Th ey in clu de cells th at are prim arily broblasts. Th eir blood su pply en ters at th e bon ey in sertion s, an d is distribu ted th rou gh an in trin sic m icrovascu lar system . Ligam en ts h ave m ore elastin , proteoglycan s, an d w ater, bu t less collagen th an ten don s, an d are m ore m ech an ically com plian t. Th eir ailu re, th rou gh sequ en tial ru ptu re o collagen ber bu n dles, is m ore gradu al an d m ore likely to be partial th an th at o th e typical ten don .

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Stru ctu ral m u scle in ju ries, in volvin g partial an d com plete tears, are typically produ ced by in direct orces opposed to pow er u l m u scle con traction . Su ch ten don disru ption s com m on ly occu r at th e m yoten din ou s ju n ction , or at th e ten don bon e in sertion site. Pen etratin g in ju ries w ith associated ten don laceration s are an oth er com m on m ech an ism o ten don in ju ry, especially in th e h an d an d w rist. As m an y o th ese types o in ju ries can be treated su ccess u lly w ith im m obilization , th is ch apter w ill ocu s on stru ctu ral m u scle an d ten don in ju ries. 3 3

Prin cip le s o f liga m e n t a n d t e n d o n

e a lin g

Both ligam en ts an d ten don s h eal by processes sim ilar to oth er tissu es. How ever, u n like bon e, th eir h ealin g does n ot in volve regen eration , so th at scar tissu e, w eaker an d m ore viscoelastic th an n orm al tissu e, alw ays rem ain s at th e site o repair. Maxim u m stren gth requ ires a n u m ber o m on th s to be ach ieved, an d is alw ays redu ced. Repaired ten don s typically on ly reach tw o-th irds o n orm al stren gth a ter several years (see Ta le Healin g stages o ligam en ts an d ten don s). Kn ow ledge abou t th e actors a ectin g h ealin g an d clin ical application s h as progressed sign i can tly over th e past ew decades. Ligam en ts th at are in traarticu lar (eg, cru ciate ligam en ts o th e kn ee) an d h ave in -su bstan ce tears h eal poorly w ith direct repair, w h ich h as been discarded in avor o recon stru ction w ith au to- or allogra ts o sim ilar tissu e. On th e oth er h an d extraarticu lar ligam en ts (eg, kn ee m edial collateral ligam en t), even w ith com plete tears, h eal better, an d o ten ach ieve satis actory resu lts w ith closed n on operative m an agem en t. Ligam en t stren gth is redu ced by im m obilization , bu t excessive stress sh ou ld be avoided u n til h ealin g h as progressed. Ligam en t h ealin g is also im paired by in creasin g age, sm okin g, n on steroidal an tiin f am m atory dru gs, diabetes m ellitu s, an d alcoh ol in take.

With ew exception s, ten don s th at are com pletely divided w ill n ot h eal w ith ou t su rgical repair. For m axim u m e ectiven ess, particu larly or sh eath ed ten don s, th is repair m u st lim it tissu e trau m a as m u ch as possible, preserve vascu larity, approxim ate ten don en ds w ith m in im al gappin g, an d provide su cien t m ech an ical stren gth to perm it early gen tle (passive) ten don m otion , w h ich m in im izes u n ction im pairin g adh esion s an d im proves th e m ech an ical properties o th e h ealin g tissu e. It h as becom e w ell accepted th at ten don s h eal th rou gh a com bin ation o both in trin sic an d extrin sic processes. Clin ically applicable tech n iqu es h ave n ot yet been sh ow n to prom ote on e h ealin g process over th e oth er. n ury

Hemorrhage and coagulation occur. These release inflammatory mediators beginning the processes of repair.

n ammation

Accumulation of neutrophils and macrophages Angiogenesis begins Production of type III collagen

1–7 days

Proliferation/ organogenesis

Angiogenesis proceeds Inflammation gradually resolves Abundant disorgani ed collagen accumulates Initially type III it is gradually replaced by type I Healing ligaments and tendons are weakest during this period

7–21 days

Remodeling

Increased collagen cross-linking Gradual normali ation of tissue components and reorgani ation of structure towards normal

egins by 2–3 weeks continues up to 18 months

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e aling stage s of ligam e nts and te ndons

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Author Kame l A

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Man y ligam en t an d ten don in ju ries respon d w ell to n on operative treatm en t. Th is is especially tru e or partial disru ption s, w h ich are th e m ajority o in ju ries. How ever, su rgical repair is pre erable or com plete ten don disru ption s th at cau se u n ction al im pairm en t, especially th ose o th e h an d, kn ee exten sors, an d an kle. Ach illes ten don ru ptu res are a som ew h at con troversial exception , w ith w ell docu m en ted good ou tcom es rom u n ction al n on operative care. Man y ligam en ts th at experien ce com plete disru ption also respon d w ell to n on operative m an agem en t, bu t im portan t exception s are th ose th at resu lt in join t su blu xation or dislocation , an d also th ose in volvin g th e in traarticu lar cru ciate ligam en ts o th e kn ee.

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Motion o th e sh ou lder occu rs prim arily at tw o sites (see ig ). Th e rst is betw een th e scapu la an d th e th orax, du rin g w h ich th e clavicle pivots u pon th e stern u m , th rou gh th e stern oclavicu lar join t. A sm all am ou n t o m otion also occu rs n orm ally at th e rath er stable acrom ioclavicu lar join t. Th e secon d site o sh ou lder m otion is th e m u ch less con strain ed glen oh u m eral join t. Th is ball an d socket diarth rodial join t allow s gen erou s m u ltiplan ar m otion , lim ited at th e extrem es by th icken ed region s o its capsu le, re erred to as capsu lar ligam en ts. Con cen tric align m en t o th e sh ou lder is su pported by th e brocartilagin ou s glen oid labru m , as w ell as th e rotator cu ten don s o teres m in or, in raspin atu s, su praspin atu s, an d su bscapu laris, an d also th e oth er region al m u scles in sertin g on th e proxim al h u m eru s.

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A large variety o path ologic processes in volve on e or m ore o th e sh ou lder region stru ctu res. Becau se o its m obility an d exposu re to direct in ju ry as w ell as in direct leverage orces, th is region ’s join ts an d associated so t tissu es are su sceptible to trau m atic an d repetitive u se in ju ries. Except or in ju ries to th e su bcu tan eou s acrom ioclavicu lar (AC) region , precise iden ti cation o th e cau se o sh ou lder sym ptom s can be ch allen gin g du e to th e m an y possible cau ses o pain an d im paired u n ction .

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The conne ctive tissue anatom of the shoulde r oint

igam e nts Acrom ioclavicular ligam e nt capsule Coracoclavicular ligam e nts

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Coracoacrom ial ligam e nt Coarcohum e ral ligam e nt le nohum e ral ligam e nts capsule

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Muscle s te ndons ante rior Supraspinatus m uscle

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Muscle s te ndons poste rior Supraspinatus m uscle Infraspinatus m uscle Te re s m inor muscle

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Author Kame l A

S o u ld e r liga m e n t a n d t e n d o n in u rie s

Mu scle an d ten don in ju ries, w h eth er rom acu te trau m a or repetitive stress, can in clu de dam age to th e ten don s or m u scles o th e rotator cu as w ell as o th e biceps or triceps m u scles. On occasion , th e m u scles th at attach th e u pper arm an d sh ou lder to th e ch est (pectoral m u scles), th e back (latissim u s dorsi, teres m ajor), or th ose th at stabilize th e scapu la (trapeziu s, rh om boids) can also be in ju red. Mu scle strain s, typically o th e u n ction al variety, an d som etim es associated w ith ten din itis an d/ or bu rsitis, m ost com m on ly occu r in th e dom in an t arm an d can be th e resu lt o a orceu l eccen tric m u scle con traction . Th e su bacrom ial bu rsa lies betw een th e su perior portion o th e rotator cu ten don s an d th e acrom ion an d lateral clavicle. A com m on sou rce o pain in th is region , aggravated by sh ou lder abdu ction an d overh ead activities, is in f am m ation o th e bu rsa an d adjacen t ten don s, o ten related to th eir bein g m ech an ically irritated by pin ch in g (im pin gem en t) betw een th e h u m eru s an d th e overlyin g coracoacrom ial arch . Progressive dam age to th is portion o th e rotator cu , w h ich h as a lim ited local blood su pply, leads to attrition al tears o th e cu ten don s, especially th e su praspin atu s.

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Ligam en t an d ten don in ju ries o th e sh ou lder are u su ally iden ti ed by th e stru ctu re(s) in volved. Th e m ost com m on sh ou lder ligam en t in ju ries, u su ally rom orces stron g en ou gh to stretch an d/ or tear th e ligam en ts w ith ou t cau sin g th e sh ou lder to ractu re or dislocate, in volve th e AC join t ( ig . How ever, th e capsu lar ligam en ts o th e glen oh u m eral (GH) join t, an d th e brocartilagin ou s glen oid labru m can be in ju red by dislocation an d su blu xation . Tears o th e labru m are com m on cau ses o GH in stability an d recu rren t dislocation , as w ell as activity-lim itin g pain . Particu larly in m iddle aged an d older in dividu als, sh ou lder capsu lar con tractu re (or “ rozen sh ou lder”) can develop w ith pain an d sign i can tly lim ited m otion . In act, loss o sh ou lder m otion is com m on w ith alm ost an y pain u l sh ou lder con dition . Preven tion o th is com plication is im portan t an d requ ires gen tle passive or assisted ran ge o m otion (ROM) exercises, begin n in g as soon as possible a ter th e on set o th e sh ou lder problem , an d repeated several tim es a day.

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Acrom ioclavicular oint in urie s

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a T pe I, partiall torn acrom ioclavicular ligam e nt without displace m e nt

T pe II, te aring and stre tching of m ore ligam e nt be rs, with minim al displace m e nt c T pe III com ple te te ars of acrom ioclavicular and coracoacromial ligam e nts, allowing signi cant upward displace m e nt of the late ral clavicle

igame nt and tendon in urie s

cro m io cla vicu la r s p ra in s

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Acrom ioclavicu lar ligam en t in ju ries are graded accordin g to th e severity o ligam en t dam age an d th e resu ltin g am ou n t o join t displacem en t (prom in en ce o distal clavicle above th e acrom ion ) [3]. Rockw ood’s addition al categories (n ot sh ow n ) re er to in creased AC displacem en t. Th ose in ju ries are stron g in dication s or su rgical redu ction an d ligam en t repair or recon stru ction . In m ost cases, n on operative treatm en t is recom m en ded or AC in ju ries u n less a ru ptu re o th e a ected ligam en t, m u scle, or ten don is presen t resu ltin g in sign i can t in stability or w eakn ess o th e sh ou lder.

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Acrom ioclavicu lar dislocation s in older patien ts are typically treated n on operatively u n less th e patien t en gages in h eavy overh ead w ork or is very active. Pain redu ction m ay be ach ieved w ith a clavicle ban dage (see ch apter 18.2 Clavicle ban dage), or else a slin g or Gilch rist ban dage (see ch apter 18.3 Gilch rist ban dage). In th e past, variou s straps an d ban dage devices w ere proposed to m ain tain redu ction o an AC dislocation (m ost o w h ich are easy to redu ce w ith m an u al pressu re bu t h ard to m ain tain ) bu t n on operative attem pts to m ain tain redu ction all carry th e risk o skin breakdow n at th e sh ou lder or elbow . Fortu n ately, or m ost patien ts, a prom in en t lateral clavicle resu ltin g rom AC dislocation is largely a cosm etic de orm ity. I correction is desired, su rgical treatm en t is advised.

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in o r a n d m o d e ra t e s o u ld e r s p ra in s a n d s t ra in s

Min or an d m oderate sh ou lder sprain s an d m u scle an d ten don in ju ries are in itially treated w ith rest, cold th erapy, an d n on steroidal an tiin f am m atory dru gs (NSAIDs) in order to h elp redu ce pain u l sym ptom s. A slin g or Gilch rist ban dage ( ig 3 ) (see ch apter 18.3 Gilch rist ban dage) can be u sed or th e rst ew days ollow in g in ju ry in order to allow sym ptom s o acu te pain to su bside. How ever, prolon ged im m obilization can lead to sh ou lder sti n ess an d delayed recovery. Early assisted ROM exercises sh ou ld be per orm ed as tolerated in order to prom ote h ealin g an d redu ce th e risk o sign i can t sti n ess. Alth ou gh m in or in ju ries w ill typically h eal w ith n on operative treatm en t, grade 2 in ju ries m igh t addition ally requ ire ph ysical th erapy in order to im prove ROM an d prom ote m u scle stren gth en in g.

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Exam ple of a com m e rciall available

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

ilchrist bandage

Klaus Dre sing, Pe te r Trafton

Author Kame l A

Sh ou lder m u scles an d ten don s o th e rotator cu th at h ave su stain ed u ll-th ickn ess tears m ay requ ire su rgery to re attach th e ru ptu red ten don , to trim torn ten don bers (debridem en t), or to repair labral cartilage tears (SLAP lesion s). Im pin gem en t on th e su praspin atu s ten don by bon e or ligam en t o th e coracoacrom ial arch m ay also ben e t rom su rgical decom pression . In f am m ation arou n d th e biceps lon g-h ead ten don , or ru ptu re o th is ten don , m igh t also requ ire eith er operative or n on operative treatm en t. 4

e a ilit a t io n

Th e goals o reh abilitation are to decrease pain an d restore u ll u n ction w ith a pain less m obile sh ou lder. Reh abilitation sh ou ld ocu s on restorin g a u ll ROM an d stren gth w h ile m ain tain in g in depen den ce in activities o daily livin g. Wh ile th e goal is to retu rn to th e prein ju ry statu s, th e severity o in ju ry w ill a ect th e speed o reh abilitation . Protocols or reh abilitation m u st con sider th e type o m an agem en t (operative versu s n on operative) an d sh ou ld be gu ided by th e treatin g ph ysician . A ter th e in itial 48 h ou rs, th e n ext ph ase o reh abilitation sh ou ld ocu s on ach ievin g ROM, an d th en gradu ally stren gth en in g th e in volved stru ctu res. Modalities su ch as ice an d h eat m ay be u sed in order to con trol edem a an d acilitate participation in ph ysical th erapy. In som e cases, pain con trol can also be ach ieved by u sin g th erapeu tic u ltrasou n d or ion toph oresis [4]. How ever, in cases o in f am ed ten don s, u ltrasou n d is con train dicated as it m ay w orsen th e in ju ry [5]. Patien ts sh ou ld be in stru cted du rin g early f exibility

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Severe sh ou lder sprain s an d strain s can in itially be treated w ith a slin g or Gilch rist ban dage an d cold th erapy, bu t m an y cases requ ire su rgery in order to repair th e ru ptu red ligam en t, m u scle, or ten don .

exercises in order to restore passive ollow ed by active m ovem en t in order to preven t th e developm en t o sh ou lder join t sti n ess (adh esive capsu litis), w h ich can severely a ect recovery. Stren gth en in g exercises are in itiated, begin n in g w ith isom etric exercises an d scapu loth oracic m u scle stren gth en in g, n ally progressin g to all a ected m u scles, in clu din g th e rotator cu , w ith in pain less ROM. Patien ts are in stru cted in th e proper postu ral m ech an ics in regard to reach in g activities as w ell as in exercises to advan ce proprioception an d activity-speci c stren gth en in g [5]. A h om e program sh ou ld be tau gh t to com plem en t su pervised reh abilitation an d to be con tin u ed a ter th e com pletion o ph ysical th erapy.

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Patien ts w ith sh ou lder sprain s an d m u scu lar in ju ries h ave a good u n ction al ou tcom e w ith n on operative treatm en t in th e m ajority o cases. Stu dies h ave sh ow n th at su ccess u l ou tcom es w ith n on operative treatm en t or m in or an d m oderate rotator-cu tears ran ge betw een 33% an d 90% o th e tim e, w ith older patien ts requ irin g lon ger recovery tim e. In gen eral, you n ger patien ts w ill m ore likely h ave a good ou tcom e th an older patien ts [6]. An d w h ile reru ptu re rates (determ in ed by MRI) ollow in g repair o rotator-cu tears can be as h igh as 50% , clin ically, th e m ajority o th ese patien ts rem ain m in im ally sym ptom atic [7]. Biceps ten don lesion s, ran gin g rom ten din itis to com plete ru ptu re, are com m on ly associated w ith rotator-cu ten don tears. Follow in g biceps ten don ru ptu re an d su rgical repair, ou tcom es are u su ally good, alth ou gh stren gth de cits m igh t rem ain ollow in g recovery. I a sym ptom atic SLAP lesion is also presen t, satis actory ou tcom es gen erally requ ire arth roscopic su rgery in order to repair th e torn cartilage. Severe rotator cu tears an d sh ou lder sprain s h ave a poorer progn osis, an d are associated w ith a h igh er degree o con tin u in g disability.

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5 l o in u rie s

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Th e u ln ar collateral ligam en t o th e elbow is critical or valgu s stability o th e elbow an d is kn ow n as th e prim ary elbow stabilizer [8, 9]. Th e elbow u ln ar collateral ligam en t (UCL) plays an im portan t role in m ost th row in g sports, in clu din g baseball, javelin , racqu et sports, an d ice h ockey. Most o th e elbow in ju ries in you n g th row in g ath letes are ch ron ic, w ith persisten t pain an d in stability rom repetitive valgu s stress on th e elbow w ith th e arm overh ead. An atom ically, th e origin o th e UCL is th e posterior distal aspect o th e m edial epicon dyle; its in sertion is at th e base o th e coron oid process. At 90º f exion , it provides 55% o th e resistan ce to valgu s stress at th e elbow ( ig 4 ).

u ln a r co lla t e ra l liga m e n t re p e t it ive u s e

In m an y sports activities, th e acceleration ph ase o th e overh ead th row cau ses th e greatest am ou n t o valgu s stress to th e elbow [10]. Elbow exten sion velocities can ran ge u p 494° per secon d an d con tin u e to 20º o f exion [11]. Du rin g a th row , th e orearm lags beh in d th e u pper arm an d gen erates valgu s stress, w ith sign i can t ten sion in th e UCL. In th is ph ase o th row in g, valgu s stress can exceed th at tolerated by th e UCL in cadavers. Th is valgu s orce can cau se eith er ch ron ic m icroscopic tears or acu te ru ptu re o th e UCL. Th e m ost com m on sym ptom o UCL repetitive-u se in ju ry is m edial elbow pain in a th row in g ath lete. Pain can be especially prom in en t du rin g th e acceleration ph ase o th e overh ead th row . Pain is o ten ch ron ic or recu rren t, an d im pairs th row in g per orm an ce. A ph ysical exam in ation can disclose th e ollow in g: • Medial elbow ten dern ess an d sw ellin g – Ten dern ess is com m on ly ou n d approxim ately 2 cm distally to th e m edial epicon dyle. Uln ar collateral ligam en t ten dern ess can occasion ally be di cu lt to di eren tiate rom f exor pron ator ten din itis, bu t th e pain o f exor pron ator ten din itis is aggravated by resistin g orearm pron ation • Occasion al loss o elbow ROM • Ecch ym osis w ith acu te ru ptu re over th e m edial elbow • Pain w h en clen ch in g th e st • Valgu s stress w ith th e elbow in 25° o f exion (elbow -abdu ction stress test) gen erates pain an d m ay cau se join t open in g. Th e a ected side sh ou ld be com pared w ith th e con tralateral elbow as a re eren ce or baselin e laxity.

ig 4 Anatom ical drawing of the e lbow oint in m e dial vie w

e xion

Trice ps brachii te ndon ice ps brachii te ndon 2

Annular ligam e nt

3

lnar collate ral ligam e nt 1

4

4

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Author Kame l A

5

e a ilit a t io n p ro gra m

Recom m en ded ph ysical th erapy in clu des: • Stabilization w ith elbow ban dage or orth osis • Gen erally 3–6 m on th s o n on operative th erapy w ith rest • Man datory local ph ysical th erapy or im proved ROM.

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Pro gn o s is

n

5 4

Proper th row in g biom ech an ics are im portan t or ath letes, an d sh ou ld be tau gh t an d m on itored by coach es, especially or you n ger players. Th orou gh w arm -u p an d f exibility exercises are also m an datory to h elp preven t in itial or re in ju ry.

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A sh ort period o im m obilization w ith a dorsal u pper-arm cast or splin t ( ig 5 ) or stabilization w ith an elbow ban dage is recom m en ded (see ch apters 15.1 Lon g arm splin t u sin g plaster o Paris; 15.2 Lon g arm splin t u sin g syn th etic; 15.3 Lon g arm cast u sin g plaster o Paris; 15.4 Lon g arm cast u sin g syn th etic, com bicast tech n iqu e; an d 18.5 Elbow ban dage). Non steroidal an tiin f am m atory dru gs m ay be u sed brief y or pain relie .

Recom m en ded ph ysical th erapy in clu des: • Flexibility an d stren gth train in g o th e elbow , w h ich are u se u l du rin g th e m ain ten an ce ph ase in order to preven t recu rren t in ju ry • Du rin g th e m ain ten an ce ph ase, particu lar atten tion to th e patien t’s th row in g tech n iqu e is essen tial in order to preven t recu rren ce o in ju ry.

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No n o p e ra t ive t re a t m e n t—a cu t e p a s e Im m o ili a t io n it a ca s t o r s p lin t

No n o p e ra t ive t re a t m e n t—m a in t e n a n ce p a s e e a ilit a t io n p ro gra m

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5 5

5 3 5 3

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X-rays m ay sh ow an avu lsion ragm en t or, in a m in ority o patien ts, can reveal secon dary n din gs su ggestive o UCL in ju ry, su ch as ossi cation o th e ligam en t. X-rays are also h elp u l in order to exclu de oth er cau ses o elbow pain , su ch as epitroch lear osteoph ytes, m edial epicon dylar apoph yseal abn orm alities, loose bodies, or osteoch on dral ractu res, especially o th e capitellu m [12].

A retu rn to com petitive th row in g is possible a ter su ccess u l reh abilitation an d recon stru ction , i in dicated. Be ore th is is con sidered, th e ollow in g criteria sh ou ld be m et [13]: • Th e ath lete is ree o pain w h en th row in g • Elbow an d sh ou lder ROM are w ith in n orm al lim its • Forearm stren gth h as retu rn ed to baselin e • Good th row in g biom ech an ics h ave been establish ed.

On ce pain an d sw ellin g h ave com pletely resolved an d th e ath lete h as retu rn ed to a prem orbid ROM, u su ally n ot be ore 3 m on th s o treatm en t, th row in g activities can gradu ally be resu m ed w ith care u l su pervision as du ration o train in g an d th row in g velocity are progressively in creased.

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Dorsal arm splint with sling

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igame nt and tendon in urie s

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Th e h an d is vital or m ost h u m an activities. Its m otor pow er is provided by f exor an d exten sor ten don s. Motion in th e h an d an d w rist occu rs th rou gh a variety o join ts: in terph alan geal, m etacarpoph alan geal, m etacarpocarpal, in tercarpal, an d radiocarpal. Each o th ese is su pported by ligam en ts th at provide or both m otion an d stability in join tspeci c plan es. 6

ln a r co lla t e ra l liga m e n t , t u m m e t a ca rp o p a la n ge a l o in t

Ru ptu re o th e u ln ar collateral ligam en t o th e th u m b’s m etacarpoph alan geal join t is n ot u n com m on ( ig 6 ), an d can lead to lon g-term problem s i in adequ ately treated. Excessive valgu s stress applied to th e th u m b m etacarpoph alan geal (MCP) join t can in ju re its UCL, typically by avu lsion rom its in sertion on th e base o th e proxim al ph alan x. Th e avu lsion can in clu de a ractu re ragm en t rom th e ph alan x, or can tear th e ligam en t aw ay rom th e base o th e ph alan x. Th e ree distal en d o th e ligam en t can displace on to th e dorsal su r ace o th e addu ctor pollicis apon eu rosis. Th is displacem en t (called a Sten er lesion ) preven ts th e ligam en t rom h ealin g back to its bon y in sertion site, an d resu lts in persisten t MCP in stability w ith w eakn ess o th u m b pin ch an d grasp.

a n d liga m e n t a n d t e n d o n in u rie s

In ju ries an d disorders o th e ten don s an d o th e join ts an d th eir ligam en ts are n u m erou s. Casts an d splin ts play im portan t roles in th eir care. How ever, it m u st be rem em bered th at h an d m obility is a cru cial part o h an d u n ction , an d th at its preservation an d restoration are absolu tely vital to th e care o h an d problem s. Th u s, an y im m obilization m u st be or n o lon ger th an n ecessary, an d m u st be ollow ed by exercises an d u n ction al u se to restore an d m ain tain m obility. Fu rth erm ore, i im m obilization is recom m en ded, th e h an d m u st be in a position th at is as u n ction al as possible, an d th at avoids sh orten in g o ligam en ts an d loss o join t m otion . Mobility o th e m ore proxim al u pper extrem ity join ts (elbow an d especially sh ou lder) is also at risk w h en th e h an d is im m obilized, sin ce lack o n orm al u se o ten resu lts in loss o m obility, especially in older patien ts an d th ose w ith arth ritis. Th ere ore, patien ts sh ou ld be advised to begin ROM exercises or all n on im m obilized join ts w h en ever a cast or splin t is applied to a portion o th e u pper extrem ity.

Ch ron ic de cien cy o th e UCL o th e th u m b MCP join t w as origin ally described in Scottish gam ekeepers, w h o repeatedly stretch ed th eir UCL w ith occu pation al tasks. More com m on ly, th e UCL ru ptu res w ith an acu te in ju ry rom a su dden abdu ction orce, as w h en a skier alls an d jam s h is or h er th u m b in to th e sn ow w h ile con tin u in g orw ard m otion . Th is in ju ry th ere ore h as tw o com m on n am es: • Gam ekeeper’s th u m b (ch ron ic) • Skier’s th u m b (acu te).

A detailed u n derstan din g o h an d an atom y an d u n ction is requ ired or diagn osis an d treatm en t o sign i can t h an d in ju ries. An excellen t u rth er sou rce o in orm ation on h an d in ju ries is available on AO Su rgery Re eren ce [14]. A selection o com m on h an d an d n ger in ju ries an d th eir treatm en t option s is sh ow n as ollow s.

Ulna collateral ligament

ig

6

6

A torn ulna collate ral ligam e nt of the thum b MCP oint

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Author Kame l A

Non operative treatm en t in volves u se o a th u m b spica cast or splin t, applied care u lly to avoid an y ten sion on th e UCL (see ch apters 15.13 Th u m b spica splin t u sin g plaster o Paris; 15.14 Th u m b spica splin t u sin g syn th etic; an d 15.16 Sh ort arm scaph oid cast u sin g syn th etic, com bicast tech n iqu e). Th is is le t or 4–6 w eeks. A sim ilar splin t or cast is recom m en ded a ter su rgical repair o th e ligam en t.

6

Pro im a l in t e rp a la n ge a l o in t s p ra in

Treatm en t con sists o sh ort-term im m obilization w ith a splin t or cast or by “bu ddy tapin g” th e in ju red n ger to an adjacen t n orm al on e, an d active ROM exercises. Th e bu ddy tapin g sh ou ld be w orn u ll tim e or 10–14 days or u n til u ll ROM h as been ach ieved. Th erea ter, i th e patien t is an ath lete, h e or sh e on ly n eeds bu ddy tapin g w h en playin g or th e rem ain der o th e season . Th e m ost com m on lon g-term con sequ en ce o PIP join t in ju ries is decreased ROM an d sti n ess. In ju red PIP join ts w ill rem ain sw ollen or u p to 6–8 m on th s, som etim es even perm an en tly. Note th at early protected m otion is a key part o treatm en t, to prom ote recovery o PIP join t m otion .

Ulna collateral ligament

Angle of joint laxity

ig

Stre ss te st for rupture d ulna collate ral ligam e nt of the thum b

Stabili e the thumb metacarpal

n i e d

In ju ries to th e collateral ligam en ts o th e proxim al in terph alan geal (PIP) join t u su ally occu r th rou gh ben din g or tw istin g. Th e resu lt is a sw ollen join t an d poin t ten dern ess over th e collateral ligam en t. I th e join t open s w h en stresstested, th e patien t h as su stain ed a grade 2 or 3 ligam en t tear. Fortu n ately, du e to th e skeletal con gu ration o th e in terph alan geal join t, ligam en t in ju ries rarely lead to ch ron ic in stability an d alm ost n ever requ ire su rgical in terven tion .

e

Fin ger proxim al in terph alan geal join ts are h in ge join ts w ith th ree m ajor ligam en ts, n am ely th e m edial an d lateral collateral, w h ich resist varu s an d valgu s orces, an d a volar (palm ar) ligam en t, th e distal portion o w h ich is brocartilagin ou s an d called th e volar plate. Sprain s an d dislocation s can dam age th ese ligam en ts. Avu lsion or im paction ractu res m ay coexist, in volvin g th e proxim al in terph alan geal articu lar su r ace.

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Diagn osis is based on in ju ry m ech an ism , pain , an d sw ellin g an d ten dern ess o th e th u m b MCP join t, an d in stability to valgu s stress o th is join t ( ig ). I th e join t is extrem ely u n stable (com pared w ith th e opposite th u m b) a com plete tear is diagn osed an d su rgical repair is advisable. I th ere is less laxity bu t pain an d ten dern ess, an in com plete tear is likely, an d n on operative treatm en t is appropriate. An x-ray th at sh ow s a n on displaced avu lsion ractu re su ggests th at n on operative treatm en t is appropriate. Wide displacem en t o an avu lsed ragm en t su ggests a Sten er lesion w ith n eed or su rgical repair. Absen ce o an avu lsion ragm en t in dicates a pu rely ligam en tou s in ju ry, th e severity o w h ich is u n certain .

igame nt and tendon in urie s

Su ggested splin t/ casts in clu de ch apters 15.17 Dorsopalm ar (u ln ar gu tter) sh ort arm splin t in clu din g tw o or m ore n gers plaster o Paris; 15.18 Dorsopalm ar (u ln ar gu tter) sh ort arm splin t in clu din g tw o or m ore n gers u sin g syn th etic; 15.19 Palm ar sh ort arm splin t in clu din g th e n gers u sin g plaster o Paris; 15.20 Sh ort arm cast in clu din g tw o or m ore n gers u sin g syn th etic, com bicast tech n iqu e; an d 15.25 Rem ovable n ger splin t u sin g syn th etic.

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o la r p la t e in u rie s o f t e fin ge rs

Th ese are cau sed by h yperexten sion o th e PIP join t. Th is in ju ry is u su ally associated w ith a dorsal dislocation or su blu xation o th e m iddle ph alan x. Th e volar plate can ail in tw o w ays: distal ru ptu re o th e volar plate, or avu lsion o its attach m en t to th e m iddle ph alan x. I th e avu lsed ragm en t is tin y (ie, in th e case o a ch ip ractu re) an d th e join t is con gru en t, treatm en t is th e sam e w h eth er or n ot a ch ip ractu re exists. A variation o dorsal block splin tin g is th e u su al regim en (see ch apter 15.25 Rem ovable n ger splin t u sin g syn th etic). Th e PIP join t is blocked 30° rom u ll exten sion , bu t th e patien t is allow ed u ll active f exion . Over th e n ext 3–4 w eeks, exten sion is in creased u n til u ll exten sion is ach ieved. How ever, i th e ch ip is large an d th e PIP join t is u n stable, su rgical in terven tion is n eeded. 6

4

le o r t e n d o n la ce ra t io n s

Th e lon g n ger f exor ten don s begin in th e orearm f exor m u scles an d in sert in th e n ger ph alan ges. Th e su per cial f exors in sert on th e base o th e m iddle ph alan ges, an d th e deep f exors on th e base o th e distal ph alan ges. Th e th u m b h as on ly a sin gle lon g f exor, w h ich attach es to th e base o its distal ph alan x. Th e lon g f exor ten don s ru n in syn ovial-

ig

lin ed sh eath s in th e w rist an d proxim al palm , an d again in th e n gers. Th e digital portion o th e f exor ten don sh eath s are rein orced by brou s th icken in g th at act as pu lleys, keepin g th e ten don s close to th e bon e an d avoidin g “bow -strin gin g” across f exed join ts. Th e en ds o a com pletely divided f exor ten don w ill separate w ith in th e sh eath , pu lled apart by f exor m u scles an d n ger exten sion . With ou t repair, th ey w ill n ot h eal. In com plete laceration s m ay resu lt in ten don irregu larities th at in ter ere w ith ten don m otion w ith in th e sh eath , so th at th ey too m igh t ben e t rom su rgery. It is essen tial to con sider th e possibility o associated digital artery an d n erve in ju ry w ith an y n ger f exor laceration . Su rgical repair o a n ger (or th u m b) f exor ten don laceration is com plex becau se o slow h ealin g, w ith risk o th e repair pu llin g apart u n til several w eeks h ave elapsed. Mech an ical protection o th e repair is th u s advisable, bu t im m obilization con tribu tes to orm ation o adh esion s th at in ter ere w ith ten don glidin g an d th u s lim it active n ger m otion . Healin g an d u ltim ate u n ction are en h an ced by m otion , bu t excessive ten don ten sion sh ou ld be avoided to protect th e ten don repair. Klein ert an d colleagu es devised a dyn am ic splin tin g program , u sin g a sh ort arm cast to an ch or elastic ban ds th at attach to th e n ails o in volved n gers ( ig ). Th e elastics passively f ex th e n gers, w h ich th e patien t is able to exten d actively again st th e elastics, th u s m ovin g th e ten don w h ile keepin g its ten sion at a low level. Th e u se o su ch a dyn am ic splin t, togeth er w ith a rigorou s su pervised th erapy program , h as becom e an in tegral part o optim al f exor ten don repair su rgery (see ch apters 15.21 Klein ert dyn am ic splin t u sin g plaster o Paris; an d 15.22 Klein ert dyn am ic splin t u sin g syn th etic, com bicast tech n iqu e).

Exam ple of a Kle ine rt d nam ic splint using plaste r of Paris

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Author Kame l A

5

le o r t e n d o n a vu ls io n —ru g

fin ge r

6

Th e so-called ru gby n ger in ju ry is an avu lsion o th e bon y in sertion o th e f exor digitoru m pro u n du s ten don in to th e distal ph alan x. Th e m ech an ism o in ju ry is a pow er u l extern al exten sion orce applied to th e distal ph alan x again st orce u l active f exion by th e w ou ld-be tackler ( ig ).

a lle t fin ge r

a s e a ll fin ge r

A m allet n ger or baseball n ger is an in ju ry to th e term in al slip o th e exten sor ten don . It is cau sed by su dden orce u l f exion o th e distal ph alan x ( or exam ple, rom a ast travellin g ball or a orce u l im pact w ith a h eavy/ solid object). Th e in ju ry can be on e o th ree types: • Stretch o th e ten don • Ru ptu re o th e ten don • Avu lsion o th e bon y attach m en t rom th e distal ph alan x.

a

b ig a ugb the re sulting de fe ct

nge r, showing m e chanism of in ur

a and signi cantl displace d avulsion of DP inse rtion with bone fragm e nt and

d i

Th e in ju red patien t w ill eel ten dern ess on th e dorsal aspect o th e distal in terph alan geal (DIP) join t an d be u n able to actively exten d th e distal ph alan x, w h ich assu m es a m alletlike f exed de orm ity.

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Treatm en t or th is in ju ry is su rgical, to restore th e f exor digitoru m pro u n du s (FDP) ten don in sertion , as w ell as to repair th e bon e de ect th at o ten sign i can tly de orm s th e distal in terph alan geal join t su r ace.

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An x-ray sh ou ld be obtain ed in order to m ake su re th e join t is con gru en t. On ly rarely is th is in ju ry n ot able to be treated w ith splin tin g w ith th e n ger in exten sion ( ig ). How ever, i volar su blu xation o th e distal ph alan x persists a ter attem pted redu ction an d exten sion splin tin g, typically becau se o a ractu re-dislocation , su rgical repair is u su ally n ecessary. Several com m ercial m allet n ger splin ts are available, or you can m ake you r ow n (see ch apter 15.26 Mallet n ger splin t u sin g syn th etic). Th e splin t sh ou ld h old th e DIP join t in u ll exten sion . Excessive h yperexten sion can com prom ise blood circu lation to th e skin over th e dorsal aspect o th e DIP join t, w ith possibility o n ecrosis an d skin slou gh . Th e splin t sh ou ld n ot in ter ere w ith ROM at th e PIP join t. Th e in ju red patien t m u st w ear th e splin t 24 h ou rs a day or 6 w eeks, th en at n igh t or an oth er 2–4 w eeks. Th e join t m u st be m ain tain ed in exten sion , even w h en ch an gin g th e splin t. I th e splin t is rem oved be ore h ealin g is adequ ate, an d a f exion de orm ity recu rs, su ccess m ay still be ach ievable w ith an oth er 6 w eek cou rse o exten sion splin tin g.

a

b ig

a

Malle t nge r

a In ur to the te rm inal slip of the e xte nsor te ndon, on dorsal aspe ct of DIP oint

A m alle t nge r splint is use d to maintain the affe cte d nge r s DIP oint in full e xte nsion

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Author Kame l A

ig outonnie re de form it , showing disruption of e xte nsor hood ce ntral slip attachm e nt to the base of the m iddle phalanx, with palmar displace m e nt of late ral bands so that the e xe rt a e xion force on the PIP oint and h pe re xte nd the DIP oint

n i e

A bou ton n ierre de orm ity can resu lt rom an in ju ry to th e digital exten sor h ood. Th e cen tral slip becom es detach ed rom th e base o th e m iddle ph alan x, an d th e lateral ban ds displace palm arly, so th ey f ex th e PIP join t w h ile exten din g th e DIP join t ( ig ). Prom pt treatm en t w ith a palm ar splin t th at m ildly h yperexten ds th e PIP w h ile allow in g active f exion exercises o th e DIP is u su ally su ccess u l. Th is splin t is w orn or 4–6 w eeks w ith gradu al w ean in g w ith atten tion to restorin g active PIP f exion ran ge. A splin t th at applies th ree-poin t con tact to th e n ger to m ain tain PIP exten sion cou ld also be u sed. Delayed treatm en t o a trau m atic bou ton n iere in ju ry m ay resu lt in perm an en t de orm ity an d im paired u n ction .

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o u t o n n ie rre d e fo rm it

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Tra u m a t ic

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igame nt and tendon in urie s

Th e kn ee is th e largest join t in th e h u m an body an d con n ects th e tibia an d bu la o th e low er leg w ith th e em u r, w ith protection in ron t by th e patella. Th e m ain elem en t is th e tibio em oral join t, an d stability to th is join t is provided by several ligam en ts ( ig , ig 3 , ig 4 ): • Medial collateral ligam en t • Lateral collateral ligam en t • An terior cru ciate ligam en t • Posterior cru ciate ligam en t.

Th e m edial collateral ligam en t (MCL) resists valgu s an gu lation o th e tibia on th e em u r. It ru n s betw een th e m edial epicon dyle o th e em u r an d th e an terom edial aspect o th e proxim al tibia. Its deep portion is attach ed to th e m edial m en iscu s. Th e lateral collateral ligam en t (LCL) resists varu s an gu lation o th e tibia on th e em u r. It ru n s betw een th e lateral epicon dyle o th e em u r an d th e h ead o th e bu la. Th e LCL is closely related to oth er posterolateral corn er stru ctu res: th e popliteo bu lar ligam en t, th e posterolateral kn ee capsu le, an d th e popliteu s m u scle. Th ese stru ctu res are im portan t rotation al stabilizers.

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ig Kne e —cruciate and collate ral ligam e nts e xion anterior vie w

Ante rior cruciate ligam e nt

ight ne e in

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Kne e —m e dial collate ral ligam e nt anatom

Supe r cial m e dial collate ral ligam e nt De e p m e dial collate ral ligam e nt

Poste rior cruciate ligam e nt Me dial cond le of fe mur articular surface Me dial m e niscus Me dial collate ral ligam e nt Me dial cond le of tibia Tube rosit of tibia e rd s tube rcle e ad of bula Transve rse ligam e nt of ne e ateral m e niscus ateral collate ral ligam e nt ateral cond le of fe mur articular surface

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Author Kame l A

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Th e posterior cru ciate ligam en t (PCL) preven ts posterior displacem en t o th e proxim al tibia relative to th e em oral con dyles. It ru n s betw een th e attach m en ts on th e posterior part (h en ce posterior cru ciate) o th e tibial plateau an d th e m edial aspect o th e in tercon dylar n otch o th e em u r [15–19].

In addition to th ese ligam en ts, th e kn ee area in clu des th e base o th e qu adriceps an d th e patella ten don . Th e patellar ten don attach es th e distal pole o th e patella to th e tibial tu bercle. It is actu ally a ligam en t th at con n ects tw o di eren t bon es, th e patella an d th e tibia. Th e patella is attach ed to th e qu adriceps m u scles by th e qu adriceps ten don ( ig 5 ). Workin g togeth er, th e qu adriceps m u scles, qu adriceps ten don , an d patellar ten don exten d th e kn ee [16, 20].

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Th e an terior cru ciate ligam en t (ACL) con trols rotation al m ovem en t an d preven ts orw ard m ovem en t o th e tibia in relation to th e em u r. It ru n s betw een th e attach m en ts on th e an terior aspect o th e tibial plateau an d th e posterolateral aspect o th e in tercon dylar n otch o th e em u r.

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ate ral m e niscus e ad of bula Me dial cond le of tibia Me dial collate ral ligam e nt Me dial m e niscus Me dial cond le of fe m ur articular surface

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igame nt and tendon in urie s

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n e e liga m e n t a n d t e n d o n in u rie s

Kn ee ligam en t in ju ries are bu t on e o m an y poten tial cau ses o disability related to th is join t, w h ich is so im portan t or ath letics an d vocation as w ell as activities o daily livin g. A correct diagn osis is very valu able, bu t n ot strictly requ ired or every less severe episode o kn ee discom ort. Th ese w ill requ en tly respon d to rest, w ith gradu al resu m ption o activity an d perh aps som e orm al th erapeu tic exercise w ith ou t iden ti cation o th e exact cau se. Failu re to im prove requ ires reassessm en t. Th e diagn ostic criteria or ligam en t in ju ries (described in topic 2 Diagn ostics) w ill h elp w ith th eir iden ti cation : localized ten dern ess, pain on ligam en t stress, an d laxity varyin g w ith in ju ry severity. An in traarticu lar ligam en t tear (eg, an terior cru ciate ligam en t) o ten produ ces a rapidly developin g join t e u sion (h em arth rosis). A sign i can t m u ltiligam en tou s tear m ay produ ce sw ellin g, an d perh aps ecch ym osis, bu t o ten n o palpable e u sion becau se th e capsu le is torn an d can n ot con tain f u id. Min or ligam en t in ju ries can be pain u l an d in ter ere w ith w eigh t bearin g activities, bu t do n ot produ ce m ech an ical in stability. How ever, pain an d m u scle in h ibition o ten resu lt in u n ction al in stability so th at a patien t m ay report th at th e in ju red kn ee eels u n stable or u n tru stw orth y. With in creasin g ligam en t dam age, in stability is eviden t on ph ysical exam in ation , w ith laxity on m an eu vers th at stretch th e in ju red ligam en t, bu t an en d-poin t is elt. Still m ore severe kn ee ligam en t in ju ries, w ith com plete ru ptu res, exh ibit laxity w ith ou t a con vin cin g en dpoin t. Kn ee ligam en t in ju ries m ay in volve on ly on e ligam en t, bu t w ith in creasin g severity, m u ltiple ligam en ts are dam aged. Th is can be associated w ith eviden t or occu lt kn ee dislocation . It is very im portan t to recogn ize th ese h igh ly u n stable kn ee in ju ries sin ce th ey m igh t in clu de a popliteal artery disru ption or blockage th at places th e low er leg at risk o isch em ic n ecrosis an d am pu tation . Th e rst in dication o su ch a vascu lar in ju ry is u su ally cal pain , w ith progressive w eakn ess an d decreased sen sation . Distal pu lses are u su ally redu ced or absen t, an d sh ou ld alw ays be ch ecked a ter a kn ee in ju ry as recogn ition o an arterial in ju ry an d u rgen t re erral m ay save a leg.

Less severe kn ee ligam en t in ju ries respon d w ell to n on operative care, especially i th ey in volve on ly a sin gle collateral ligam en t. Tears o th e ACL th at produ ce sign i can t in stability are best treated w ith su rgical recon stru ction . Th e sam e is tru e or in -su bstan ce com plete tears o th e PCL, bu t i th e PCL is avu lsed rom its attach m en t to th e posterior tibial plateau , reattach m en t w ith correct ten sion is o ten su ccess u l. Mu ltiple ligam en t in ju ries, w ith greater in stability, are also m ore o ten m an aged su rgically i th is is available. With ou t a stron g in dication or su rgical repair, a trial o n on operative m an agem en t is reason able, ollow ed by delayed recon stru ction i u n ction ally sign i can t in stability rem ain s. Patien ts w ith prim arily seden tary job du ties an d low -dem an d activities o daily livin g can be treated n on operatively w ith expectation o a good ou tcom e or regain in g stability o th e join t. Ten don tears in th e kn ee are described as eith er partial or com plete. Partial tears do n ot com pletely disru pt th e so t tissu e (sim ilar to a rope stretch ed so ar th at som e o th e bers are torn bu t th e rope rem ain s in on e piece). A com plete tear separates th e ten don tissu e in to tw o u n con n ected pieces, a stron g in dication or su rgery.

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Author Kame l A

Co lla t e ra l liga m e n t s p ra in s

With m ore severe bu t isolated collateral ligam en t in ju ries, su rgery is u su ally n ot n eeded. Th e patien t sh ou ld rem ain in a brace or 4–8 w eeks an d th en receive ph ysical th erapy to stren gth en th e m u scles th at h elp provide u n ction al join t stability (see ch apters 16.3 Cylin der lon g leg cast u sin g syn th etic, com bicast tech n iqu e; an d 16.4 Hin ged kn ee brace). Active ROM is in itiated early in order to preven t sti n ess w ith con com itan t stren gth en in g exercises. Fin ally, on ce a patien t’s stren gth an d proprioception h ave recovered to levels com parable to th e con tralateral side, th e patien t m ay retu rn to sports activities.

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I th e clin ical n din gs o a su spected cru ciate ligam en t in ju ry do n ot in dicate a stru ctu ral ACL or PCL tear or an associated m en iscal in ju ry, n on operative treatm en t w ith RICE, ph ysical th erapy, an d bracin g can be in trodu ced (see ch apters 16.3 Cylin der lon g leg cast u sin g syn th etic, com bicast tech n iqu e; an d 16.4 Hin ged kn ee brace). In n on operative treatm en t, progressive ph ysical th erapy an d reh abilitation can restore th e kn ee to a con dition close to its prein ju ry state. Moreover, th e patien t sh ou ld be train ed on h ow to preven t in stability. How ever, m an y people selectin g n ot to h ave su rgery m ay experien ce secon dary in ju ry to th e kn ee du e to repetitive episodes o in stability.

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Non operative treatm en t or grade 1 or 2 collateral kn ee ligam en t sprain s in clu des th e ollow in g: • Rest, ice, com pression , an d elevation (see topic 9 RICE regim en ) an d prescription o NSAIDs are th e u su al treatm en ts du rin g th e rst 24–72 h ou rs a ter an in ju ry • Cru tch es can be u sed on a sh ort-term basis in order to preven t w eigh t bearin g on th e a ected kn ee • Kn ee im m obilizers are advisable bu t sh ou ld be u sed on ly or a ew days to exclu de m u scle atroph y (see ch apter 16.4 Hin ged kn ee brace) ( ig 6) • Ph ysical th erapy or establish m en t o a h om e exercise program can be started a ter 72 h ou rs to begin ROM an d gradu al w eigh t bearin g • A brace can also be u sed or grade 2 sprain s or 4–6 w eeks in order to preven t rein ju ry (see ch apter 16.4 Hin ged kn ee brace) • Th rom bosis proph ylaxis sh ou ld be con sidered, especially or h igh er risk patien ts (see ch apter 4 Th rom bosis proph ylaxis).

Cru cia t e liga m e n t s p ra in s

Su rgical treatm en t is recom m en ded in com bin ed ACL in ju ries (ie, ACL tears in com bin ation w ith oth er in ju ries in th e kn ee). How ever, decidin g again st su rgery m ay be reason able or selected patien ts. Non operative m an agem en t o isolated ACL tears is likely to be su ccess u l or m ay be in dicated in th e ollow in g patien ts: • With partial tears an d n o in stability sym ptom s • With com plete tears an d n o sym ptom s o kn ee in stability du rin g th e patien t' s pre erred activities • Willin g to give u p h igh -dem an d sports • Doin g ligh t m an u al w ork or w ith seden tary li estyles • With open grow th plates (ie, ch ildren ) [18, 21, 22].

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I th e PCL on ly is in ju red, it can also be treated w ith ou t su rgery. Th e in ju ry can occu r ollow in g h yperexten sion w h ile ru n n in g, or as a resu lt o a direct blow to th e f exed kn ee, com m on in som e tacklin g sports. In itially, th e RICE regim en can speed recovery. For im m obilization , a brace is applied in order to preven t th e kn ee rom m ovin g (see ch apters 16.3 Cylin der lon g leg cast u sin g syn th etic, com bicast tech n iqu e; an d 16.4 Hin ged kn ee brace). To u rth er protect th e kn ee, cru tch es can be u sed in order to preven t pu ttin g w eigh t on th e leg. Ph ysical th erapy is recom m en ded, an d as th e sw ellin g goes dow n , a care u l reh abilitation program is started. Speci c exercises w ill restore u n ction to th e kn ee an d stren gth en th e leg m u scles th at su pport it. Stren gth en in g th e m u scles in th e ron t o th e th igh (qu adriceps) h as been sh ow n to be a key actor in a su ccess u l recovery [19, 23].

3 Pa t e lla r t e n d o n t e a rs

Th e patellar ten don o ten tears w h ere it attach es to th e kn eecap, an d can break o a piece o th e bon e as it tears. More distal tears also occu r. Sw ellin g, ten dern ess, an d a palpable de ect in th e ten don h elp to localize th e disru ption . A com plete tear is likely i th e patien t is u n able to exten d th e kn ee u lly an d keep it straigh t w h ile li tin g th e leg o th e su r ace o th e exam table (straigh t leg raisin g test). Th is test is also positive in th e case o a com plete qu adriceps ten don tear, or a displaced tran sverse patellar ractu re w ith associated tears o th e patellar retin acu la. Takin g AP an d lateral x-rays o th e kn ee h elps w ith th e assessm en t o qu adriceps m ech an ism in ju ries. Th e type o treatm en t requ ired or a patellar ten don tear depen ds on type an d size o th e tear, th e patien t’s activity level, an d age. Very sm all partial tears respon d w ell to treatm en t w ith im m obilization o th e kn ee in very sligh t f exion in an im m obilizer or brace (see ch apters 16.3 Cylin der lon g leg cast u sin g syn th etic, com bicast tech n iqu e; an d 16.5 Dorsal lon g leg splin t u sin g plaster o Paris), an d w eigh t bearin g lim ited w ith cru tch es. Stru ctu ral h ealin g is u su ally ach ieved w ith in 6 w eeks. Ph ysical th erapy, w ith speci c exercises to stren gth en th e qu adriceps m u scles, is m an datory, an d m ay begin be ore u n protected w eigh t bearin g. Straigh t leg raises are o ten prescribed. A ter som e tim e, u n lockin g o th e brace is o ten possible, allow in g m ore reedom o m ovem en t w ith a greater ROM. Most people w ith com plete or n early com plete patellar ten don tears requ ire su rgery in order to regain m ost o th e u n ction in th eir leg. Su rgical repair reattach es th e torn ten don to th e kn eecap, an d is u su ally protected w ith a cast or splin t u n til th e tissu es h ave h ealed en ou gh to begin progressive reh abilitation .

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Author Kame l A

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In m ost cases, th e origin al stren gth o th e kn ee is n ot regain ed (estim ated at 50–70% ). Isolated grade 3 ACL an d PCL in ju ries do n ot h eal as th ey are n ot con tain ed in a vascu larized bed. How ever, it is im portan t to n ote th at n ot all in ju ries lead to u n ction al disability [24, 25].

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Kn ee in ju ries h eal over th ree ph ases. Both ten don s an d ligam en ts in itially experien ce an acu te in f am m ation ph ase w ith in th e rst ew days ollow ed by a repair ph ase o several w eeks. Fin ally, in ph ase 3 th ere is rem odelin g an d m atu ration , w h ich can requ ire m an y m on th s be ore th ere is even tu al cross-lin kin g an d im proved ten sile stren gth .

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Qu adriceps ten don in ju ries are partial or com plete disru ption s o th e m yoten din ou s tissu e w h ere th e qu adriceps m u scle attach es to th e proxim al pole o th e patella. Th ey o ten propagate in to th e m edial an d lateral patellar retin acu la. Like com plete patellar ten don tears an d displaced patellar ractu res, com plete qu adriceps tears produ ce a positive straigh t leg raisin g test. Th ey requ ire su rgical repair, w ith postoperative cast or splin t, an d reh abilitation a ter h ealin g. In com plete tears, u n less large, can be treated sim ilarly to in com plete patellar ten don tears, previou sly described.

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Th ere are tw o diarth rodial join ts in th e an kle region . Th e “u pper an kle join t” (tibiotalar) is a com plex h in ge articu lation betw een a socket orm ed by th e distal tibia an d bu la, h eld togeth er by th e syn desm otic ligam en ts an d th e proxim al su r aces o th e talu s. Th is join t is su pported by its bon y arch itectu re an d collateral ligam en ts. Th e “low er an kle join t” (su btalar) betw een th e talu s an d th e calcan eu s, is an obliqu ely orien ted h in ge th at perm its in version an d eversion . Its ligam en ts are h idden in th e space betw een th ese bon es, except or th e an kle lateral collateral ligam en t’s bu localcan eal portion , w h ich crosses both join ts. Th e ten don s crossin g th e an kle provide m otor pow er an d con trol or both u pper an d low er an kle join ts, w h ich in teract du rin g n orm al gait. An kle stability is con erred by bon y arch itectu re an d capsu lar ligam en tou s stru ctu res ( ig , ig ) an d su pportin g ten don s. Wh en th e stren gth o th ese stru ctu res is exceeded, typically by torsion al orces produ ced by th e body’s kin etic en ergy actin g again st th e station ary plan ted oot, in ju ries occu r th at dam age bon e an d/ or ligam en ts in pattern s th at are airly predictable, depen din g on th e direction o th e applied orces. Man y o th ese in volve com bin ation s o bon e an d ligam en t in ju ries.

Th e calcan eo bu lar ligam en t (CFL) is a stron g, f at, oval ligam en t origin atin g rom th e lateral m alleolu s, ru n n in g deep to th e bu lar ten don s an d in sertin g on th e posterior aspect o th e lateral calcan eu s. Th is ligam en t resists in version w ith th e an kle in dorsif exion an d stabilizes both th e an kle an d su btalar join t. Th e posterior talo bu lar ligam en t (PTFL) is a very stron g ligam en t th at origin ates on th e m edial su r ace o th e lateral m alleolu s an d in serts on th e posterior su r ace o th e talu s. It is th e stron gest o th e lateral ligam en ts an d preven ts posterior an d rotatory su blu xation o th e talu s. Addition ally, th e an kle’s ten don an d n eu rovascu lar stru ctu re in clu de ve n erves, tw o m ajor arteries an d vein s, an d 13 ten don s th at cross th e an kle join t. Th ese ten don s can be divided accordin g to th eir location s: an terior, posterior, m edial, an d lateral. Th e posterior grou p in clu des th e Ach illes ten don , rom th e gastrocn em iu s an d soleu s m u scles. It is th e m ost pow er u l plan tar f exor o th e an kle an d is particu larly im portan t or stabilizin g th e position cru ral segm en t du rin g stan ce-ph ase w eigh t bearin g on th e ore oot.

Th ere are th ree m ajor portion s o th e an kle lateral collateral ligam en t com plex. Th ese are: • Th e an terior talo bu lar ligam en t • Th e calcan eo bu lar ligam en t • Th e posterior talo bu lar ligam en t.

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Th e an terior talo bu lar ligam en t (ATFL) is th e w eakest o th e th ree, an d m igh t be th e on ly portion in ju red in an in version sprain . a ig a

b Collate ral ligam e nt com ple xe s of the an le The late ral collate ral ligam e nt com ple x The m e dial collate ral ligam e nt com ple x de ltoid ligam e nt Inte rosse ous m e m brane Ante rior tibio bular ligam e nt Ante rior tibial tube rcle tube rcle of Tillaux Chaput Ante rior talo bular ligam e nt Calcane o bular ligam e nt Poste rior talo bular ligam e nt De ltoid ligam e nt Poste rior tibio bular ligam e nt

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Author Kame l A

n le liga m e n t a n d t e n d o n in u rie s

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An kle syn desm osis sprain s also occu r, bu t are less com m on . Th e an kle syn desm osis is com posed o th ree sh ort stou t ligam en ts th at rm ly u n ite th e distal tibia an d bu la, ju st proxim al to th e tibiotalar join t (an terior an d posterior in erior tibio bu lar, an d in terosseou s ligam en ts). On ly very sligh t m otion n orm ally occu rs at th e syn desm osis. How ever, orcible rotation o th e leg w ith w eigh t bearin g arou n d th e xed talu s can spread th e tibia an d bu la apart, stretch in g an d tearin g th e syn desm otic ligam en t bers an d cau sin g a “h igh an kle sprain ”. Th e location o m axim al ten dern ess h elps distin gu ish th ese tw o types o an kle sprain s. An kle syn desm osis in ju ries also occu r in association w ith m alleolar an kle ractu res, especially bim alleolar an d trim alleolar ractu res, in w h ich th e bu la is ractu red above th e syn desm osis. Som etim es a pu rely ligam en tou s syn desm otic in ju ry produ ces radiograph ically visible w iden in g o th e an kle m ortise. As w ith an kle ractu res th at sh ow sim ilar w iden in g, su rgical repair is requ ired to reposition th e bu la correctly in th e tibia’s in cisu ral n otch an d h old it th ere or th e several m on th s, w h ich is requ ired or stable h ealin g. Lesser degrees o syn desm otic sprain u su ally h eal satis actorily w ith n on operative treatm en t, bu t th ese h igh an kle sprain s h eal m u ch m ore slow ly th an th ose o th e lateral collateral ligam en t.

Poste rior vie w Inte rosse ous m e m brane Ante rior tibio bular ligam e nt Ante rior tibial tube rcle tube rcle of Tillaux Chaput Ante rior talo bular ligam e nt Calcane o bular ligam e nt Poste rior talo bular ligam e nt De ltoid ligam e nt Poste rior tibio bular ligam e nt

Ru ptu res o th e Ach illes ten don typically occu r in m iddle aged or older in dividu als du rin g ru n n in g activities, an d are o ten preceded by degen erative ch an ges in th e ten don (ten din opath y or ten din itis). Th ey are u su ally com plete, w h ich m ay be h ard to appreciate becau se active plan tar f exion , alth ou gh w eak, is preserved du e to th e in tegrity o oth er posterior ten don s (lon g f exors an d peron eals).

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Forcible in version o th e an kle an d oot can cau se partial or com plete disru ption o th e lateral collateral ligam en t. Th is com m on “an kle sprain ” is th e m ost requ en t in ju ry in th e an kle region , an d varies greatly in severity depen din g u pon th e degree o ligam en t disru ption . Ligam en tou s laxity is h ard to assess becau se in version th rou gh th e su btalar join t is n orm ally presen t. In version stress can produ ce tiltin g o th e talu s in th e an kle m ortise, bu t an x-ray taken w ith in version stress is requ ired to dem on strate th is an d distin gu ish it rom n orm al in version o th e calcan eu s th rou gh th e su btalar join t.

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So t-tissu e an kle in ju ries are com m on , particu larly am on g ath letes. In act a w ide ran ge o in ju ries rom variou s cau ses can a ect th e an kle an d its ligam en ts an d ten don s.

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Sprain s o th e lateral ligam en ts o th e an kle are th e m ost com m on m u scu loskeletal in ju ry in sports [26] an d occu r w h en th e an kle is orce u lly in verted. Th e ATFL is th e w eakest bu t resists an terior su blu xation o th e talu s in plan tar f exion o th e an kle. Its in tegrity an d laxity can be assessed w ith an “an terior draw er” orce applied m an u ally th rou gh th e oot w h ile stabilizin g th e low er leg w ith th e opposite h an d. Lateral an kle ligam en t in ju ries can be classi ed in to th ree grades: m in or (grade 1), m oderate (grade 2), an d severe (grade 3). Th e latter is u su ally con sidered to represen t com plete disru ption o a sign i can t portion o th e LCL, w ith resu ltin g in version in stability. Oth er possible diagn oses sh ou ld alw ays be con sidered: • Syn desm otic in ju ry • Peron eal ten don su blu xation • Posterior tibial ten don tear • Ach illes ten don tear • 5th m etatarsal base ractu re • Mid oot in ju ries • Lateral talar process ractu re • An terior process o calcan eu s ractu re • Osteoch on dral talar ractu re. Th e in itial care o a lateral collateral an kle sprain typically ollow s th e RICE regim en , in clu din g u sin g an elastic w rap/ ban dage (see ch apter 18.6 An kle an d oot ban dage), an d protected w eigh t bearin g.

im m obilization an d u n ction al reh abilitation (see ch apters 16.10 Dorsal sh ort leg splin t u sin g plaster o Paris; 16.11 Dorsal sh ort leg splin t u sin g syn th etic; 16.12 Sh ort leg cast u sin g rigid syn th etic; an d 16.13 Sh ort leg cast u sin g syn th etic, com bicast tech n iqu e). Su rgical repair is u su ally reserved or ch ron ic an kle in stability. Cast im m obilization typically en tails a period o 4–6 w eeks in a below -kn ee w alkin g cast (see ch apters 16.12 Sh ort leg cast u sin g rigid syn th etic; an d 16.13 Sh ort leg cast u sin g syn th etic, com bicast tech n iqu e), ollow ed by proprioceptive reh abilitation , u n ction al m an agem en t, early m obilization w ith extern al su pport, an d RICE. Th is is ollow ed by a reh abilitation program con sistin g o ROM exercises, stren gth en in g, proprioception reh abilitation , an d activity-speci c train in g. Proprioception train in g, w h ich is essen tial or th e recovery o balan ce an d postu ral con trol, con sists o a series o progressive drills on devices su ch as w obble boards an d tram polin es. In addition to providin g m ech an ical stability, extern al su pports also provide proprioceptive eedback an d th u s aid in reh abilitation . In lateral an kle sprain s, regain in g u ll ROM, stren gth , an d n eu rom u scu lar coordin ation are param ou n t du rin g reh abilitation . Isom etrics an d open -ch ain ROM exercises can be carried ou t by patien ts n ot allow ed to bear w eigh t. Ran ge o m otion exercises sh ou ld ocu s on dorsif exion an d plan tar f exion an d be per orm ed passively an d actively as tolerated. Du rin g early reh abilitation , tow el stretch es, an d w obble-board ROM exercises sh ou ld be in trodu ced as tolerated.

For grade 1 sprain s, start m obilization , ROM, an d isom etric exercises early. For grade 2 an kle sprain s, an extern al su pport su ch as an air-stirru p or an an kle splin t/ orth osis (see ch apter 16.15 Rem ovable an kle splin t u sin g syn th etic, com bicast tech n iqu e) as w ell as early ROM an d isom etric exercises are advised. Th e m ost com m on m eth ods u sed to m an age grade 3 acu te lateral an kle-ligam en t in ju ry are cast

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Author Kame l A

Patien ts w ith a sign i can t syn desm otic sprain sh ou ld typically be im m obilized in a sh ort leg n on w eigh t bearin g cast or 4–6 w eeks a ter in ju ry (see ch apters 16.10 Dorsal sh ort leg splin t u sin g plaster o Paris; 16.11 Dorsal sh ort leg splin t u sin g syn th etic; 16.12 Sh ort leg cast u sin g rigid syn th etic; an d 16.13 Sh ort leg cast u sin g syn th etic, com bicast tech n iqu e). Th e cast an d avoidan ce o w eigh t bearin g m in im ize stresses on th e syn desm osis, an d h elps avoid separation o th e distal tibia an d bu la, a m otion th at im poses stress on th e in terosseou s tibio bu lar ligam en t betw een th e distal tibia an d bu la. Th e prescription lasts or 4–6 w eeks, allow in g th e in terosseou s tibio bu lar ligam en t to h eal. Th is is ollow ed by u se o a protective, m odi ed, articu lated an kleoot orth osis th at elim in ates extern al rotation stress on th e an kle or a variable period, depen din g on th e u n ction al n eeds an d sports activities o th e patien t (see ch apter 16.15 Rem ovable an kle splin t u sin g syn th etic, com bicast tech n iqu e). More severe syn desm otic in ju ries w ith displacem en t o th e bu la an d tibia requ ire su rgical treatm en t, u n less a totally an atom ical closed redu ction can be con rm ed.

c ille s t e n d o n ru p t u re s

Most Ach illes ten don problem s are related to overu se in ju ries an d are m u lti actorial or degen erative. Th e prin cipal actors in clu de h ost su sceptibility an d m ech an ical overload. Th e spectru m o in ju ry ran ges rom paraten don itis to ten din osis to acu te ru ptu re. In a trau m a settin g, a tru e ru ptu re is th e m ost com m on presen tation . Th is is u su ally com plete, w ith a palpable de ect in th e ten don . Som etim es, partial ru ptu re can occu r. To distin gu ish betw een partial an d com plete ru ptu res, Th om pson ’s test is recom m en ded. With th e patien t lyin g pron e on th e table w ith h is or h er oot exten ded beyon d th e en d o th e table th e exam in er squ eezes th e cal . A n orm al n on in ju red respon se to th is m an eu ver is sligh t plan tar f exion o th e an kle, bu t a lack o an kle plan tar f exion m ay in dicate a ru ptu re o th e Ach illes ten don . Th e treatm en t goals or a ru ptu red Ach illes ten don are to restore n orm al m u scu loten din ou s len gth an d ten sion an d th ereby optim ize u ltim ate stren gth an d u n ction o th e gastrocn em iu s-soleu s com plex. Wh ile n on operative treatm en t u su ally resu lts in in creased m u scle-ten don len gth (ie, in creased dorsif exion ran ge an d redu ced cal m u scle bu lk), th e u n ction al resu lts o properly m an aged n on operative treatm en t or Ach illes ten don ru ptu res are sim ilar to th ose o su rgery, w ith ou t its com plication s, th u s th is approach deserves seriou s con sideration or m an y patien ts.

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Un like m ost oth er com plete ten don in ju ries, w h ich u su ally h ave a gap betw een th e ree ten don en ds, th e Ach illes ten don en ds u su ally rem ain in proxim ity particu larly i th e oot is allow ed to all in to plan tar f exion (th e position produ ced by gravity w ith ou t an y addition al orce). Perh aps becau se o th is, com plete Ach illes ten don ru ptu res can o ten be treated su ccess u lly w ith ou t su rgical repair, bu t th is requ ires a prolon ged period o im m obilization to en su re th at ten sile stren gth h as retu rn ed to th e ten don be ore sign i can t loadin g is applied. Com plete ru ptu res o th e oth er an kle f exor an d exten sor ten don s sh ou ld u su ally be con sidered or su rgical repair.

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Th e Ach illes ten don is th e largest ten don o th e h u m an body. It lacks a tru e syn ovial sh eath an d in stead is en closed in th e paraten on , w ith visceral an d parietal layers perm ittin g approxim ately 1.5 cm o ten don glide. It receives its blood su pply rom th ree sou rces: • Th e m u scu loten din ou s ju n ction • Th e osseou s in sertion • Mu ltiple m esoten al vessels on th e an terior su r ace o th e ten don .

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Syn desm otic sprain s are less requ en tly en cou n tered. Th e in terosseou s ligam en ts betw een th e tibia an d bu la w ill be ru ptu red w ith or w ith ou t a bu lar ractu re an d w ith or w ith ou t ran k diastasis. How ever, im m ediate an d spon tan eou s redu ction u su ally occu rs, m akin g th e diagn osis ch allen gin g. Man y o th ese so-called h igh an kle sprain s probably go u n diagn osed an d w ill cau se ch ron ic an kle pain . In ju ries to th e syn desm otic ligam en ts o ten take m on th s to h eal. Tibio ibu lar syn desm otic ligam en tou s in ju ries are slow er to recover th an an y oth er ligam en tou s an kle in ju ry an d can ben e it rom a m ore restrictive approach to in itial m an agem en t.

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Som e im portan t in dication s an d risks sh ou ld be con sidered: • Approxim ation o th e ru ptu red ten don en ds, w h ich can be docu m en ted w ith u ltrason ograph y in gravity equ in u s position • Older, seden tary patien ts • Patien ts w ith in creased risk o so t-tissu e com plication s – In su lin -depen den t diabetes m ellitu s – Sm okers – Vascu lar disease. In regards to n on operative treatm en t, a low er-leg cast is applied w ith th e an kle in plan tar f exion : • Th e cast is progressively brou gh t ou t o equ in u s over a period o 8–10 w eeks • Walkin g (in th e cast) is allow ed at 4–6 w eeks • Retu rn to sports u su ally requ ires at least 4–6 m on th s • Altern atively, th e u se o a u n ction al brace m ay be con sidered, startin g in 45° o f exion • Follow in g th e period o cast im m obilization , a 2 cm h eel li t is w orn or an addition al 2–4 m on th s • It can take 12 m on th s to regain m axim al plan tar f exion pow er.

Pro gn o s is

Literatu re review s sh ow th at th e m ajority o patien ts w ith acu te an kle sprain s report u ll recovery w ith in 36 m on th s, in depen den t o th e in itial grade o sprain , w ith m ost recovery occu rrin g w ith in th e rst 6 m on th s [27, 28]. A ter 12 m on th s, th e risk o recu rren t an kle sprain retu rn s to prein ju ry levels [29]. How ever, som e patien ts report resprain s rom 2 w eeks u p to 96 m on th s a ter th e in itial in ju ry, an d a ter 3 years, patien ts can still report residu al pain an d in stability. On e risk actor or residu al sym ptom s seem s to be participation in com petitive sports [27]. Neverth eless, i a ligam en t in ju ry is treated early, an d appropriate reh abilitation is in itiated, th e progn osis is still excellen t w ith n on operative treatm en t.

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Author Kame l A

Com pression m ay h elp decrease local in terstitial f u id accu m u lation , in com bin ation w ith elevation o th e in ju red part. In practice, th e rst 1–3 days u su ally a ter a ligam en t or m u scle-ten don in ju ry sh ou ld be devoted to th e RICE regim en . Cryoth erapy accom pan ied by com pression sh ou ld be applied or 15–20 m in u tes at a tim e w ith 30–60 m in u tes betw een application s. Du rin g th is period o tim e, th e a ected region sh ou ld be kept relatively im m obile in order to allow or appropriate h ealin g an d to preven t u rth er in ju ry (see appropriate extrem ity im m obilization th rou gh ou t section 2 Gu idelin es). On ce sign i can t sw ellin g h as clearly begu n to resolve, an in itial splin t can be exch an ged or tigh ter im m obilization . For exam ple, a sh ort leg splin t m igh t be replaced w ith a w eigh t bearin g cast. Th e u se o NSAIDs can be ben e cial or redu cin g pain an d m ay allow earlier retu rn to activity. As th e lon g-term e ects o NSAIDs in m u scle strain s are yet u n kn ow n , recen t review s

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Th e acu te ph ase o treatm en t w ith RICE is ollow ed by an active ph ase o m an agem en t on ce th e in ju red part is recoverin g w ell. Th is ph ase u su ally begin s approxim ately 3–5 days a ter th e in itial in ju ry, depen din g on severity. Stretch in g, stren gth en in g, ROM exercises, m ain ten an ce o aerobic tn ess, proprioceptive exercises, an d u n ction al train in g are im portan t com pon en ts o reh abilitation du rin g th is ph ase to preserve overall tn ess w h ile acilitatin g recovery o th e in ju red stru ctu res. Stretch in g sh ou ld be per orm ed careu lly an d alw ays ju st to th e poin t o discom ort, bu t n ot pain . Variou s tech n iqu es can be u sed in clu din g passive, activepassive, dyn am ic, an d proprioceptive n eu rom u scu lar acilitation stretch in g. Gen erally, ballistic stretch in g is discou raged u n til h ealin g is w ell advan ced du e to th e risk o retearin g th e m u scle bers. An active w arm -u p sh ou ld alw ays precede an y type o reh abilitation exercises as it h as been sh ow n to activate n eu ral path w ays w ith in th e m u scle an d redu ce m u scle viscosity. Stren gth en in g exercises can begin gradu ally an d progress sequ en tially th rou gh isom etric, isoton ic, isokin etic, an d u n ction al exercises.

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Com bin ed elevation , gen tle com pression , coolin g, an d rest o th e in ju red part h ave lon g been recom m en ded or in itial care o m u scle an d join t in ju ries o th e extrem ities. A splin t or cast is o ten added, especially or m ore pain u l or m ore severe in ju ries. Mild to m oderate elevation h elps to redu ce in terstitial edem a w ith ou t low erin g per u sion pressu re, as m igh t h appen w ith extrem e elevation . Main tain in g elevation , in a sittin g or recu m ben t position , n ecessitates redu ced activity, w h ich redu ces m ech an ical stress on th e in ju red area, ren derin g it less pain u l as w ell as less likely to su stain addition al trau m a. Wh ile stron g eviden ce m ay n ot su pport aster or m ore sign i can t h ealin g [30], th e advice is sou n d w ith regard to preven tion o rein ju ry as w ell as or pain con trol. Icin g does low er in tram u scu lar tem peratu re an d decreases blood f ow to th e in ju red area. Stu dies h ave sh ow n th at cryoth erapy is e ective in decreasin g pain associated w ith m u scle in ju ry [31].

recom m en d on ly a sh ort 3–7 day period a ter m u scle strain s. In con trast, th e u se o corticosteroids is de n itely discou raged based on research dem on stratin g delayed h ealin g an d redu ced biom ech an ical stren gth o in ju red m u scle.

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All stren gth en in g exercises sh ou ld be per orm ed th rou gh a pain less ROM. Advan cin g th rou gh each type o stren gth en in g regim en depen ds on th e level o soren ess an d pain created by each type o exercise. For exam ple, or a kn ee in ju ry, on ce isom etric straigh t leg raises at 0°, 20°, an d 40° can be com pleted w ith ou t experien cin g pain or su bsequ en t soren ess, isoton ics can be in itiated. Main tain in g aerobic tn ess du rin g reh abilitation is im portan t an d can be accom plish ed by resortin g to activities like sw im m in g an d bikin g. On ce again , th ese activities sh ou ld n ot in crease th e level o pain in th e in ju red area an d sh ou ld be per orm ed w ith in a pain less ROM [24, 32, 33].

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• Ligam en ts an d ten don s con sist o a h ierarch y o h igh ly align ed collagen com posed o brils, ascicles, bers, an d th e tissu e itsel ; th ey are som e o th e stron gest tissu es in th e body an d m u st w ith stan d som e o th e greatest applied orces • Th e h ealin g o ligam en t an d ten don in ju ries is gen erally slow , goin g th rou gh th ree ph ases o repair com prisin g an im m ediate in f am m atory ph ase, an organ ogen esis ph ase, an d a rem odelin g ph ase, w h ich can con tin u e or m an y m on th s • Sh ou lder sprain s an d strain s resu lt rom orces stron g en ou gh to stretch an d/ or tear ligam en ts an d ten don s in th e AC an d GH join ts w ith ou t cau sin g th e sh ou lder to ractu re or dislocate, yet th ese in ju ries can o ten be su ccess u lly treated n on operatively u sin g a ran ge o su pport ban dages, cold th erapy, an d reh abilitation • Th e u ln ar collateral ligam en t o th e elbow is th e prim ary elbow stabilizer an d plays an im portan t role in th row in g sports, bu t it can respon d avorably to n on operative treatm en t ollow in g an in ju ry, particu larly w h en in volvin g a program o stabilization w ith su pport ban dagin g, rest, n on steroidal an tiin f am m atory dru gs, an d appropriate ph ysical th erapy • Th e h an d is su sceptible to a w ide ran ge o ligam en t an d ten don in ju ries rom su ch action s as tw istin g, overload/ overu se, an d h yperexten sion or orce u l f exion o n gers an d join ts du rin g con tact sports, yet in m an y cases th ese in ju ries can also be su ccessu lly treated n on operatively

• Th e kn ee experien ces in stability (abn orm ally in creased ROM) du e to ligam en tou s, capsu lar, m en iscal, cartilage, or bon e in ju ry/ abn orm ality. Wh ile severe ligam en t in ju ries deserve con sideration or su rgical repair or recon stru ction , less severe in ju ries, in clu din g m an y m edial collateral or isolated cru ciate ligam en t tears, as w ell as in ju ries su stain ed by patien ts w ith prim arily seden tary job du ties an d low -dem an d activities o daily livin g, can be treated n on operatively w ith a good ch an ce o regain in g a stable join t an d acceptable u n ction • Th e an kle join t, com prisin g syn desm otic ligam en ts, lateral collateral ligam en ts, an d m edial collateral ligam en ts, as w ell as a n u m ber o im portan t ten don s su ch as th e Ach illes, is su sceptible to sprain an d strain in ju ries particu larly du rin g sport, h ow ever, m ost patien ts can be su ccess u lly treated u sin g n on operative im m obilization • In m ost ligam en t an d ten don in ju ries, th e RICE regim en , bein g rest, ice, com pression , an d elevation , is an essen tial part o treatm en t, particu larly du rin g th e rst ew days a ter th e in ju ry.

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Author Kame l A

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Id le r

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gin o T, e t a l

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Author Endre arga

Nerve in uries Endre arga

3

ia gn o s t ics Ele ctrodiagnostic te sts

3

3

T p e s o f p e rip e ra l n e r ve in u rie s

3

4

Pro t e ct io n o f n e r ve s fro m t e n s io n Ph siologic lim its Postope rative prote ction

3

5

In d ica t io n s fo r p re o p e ra t ive a n d p o s t o p e ra t ive im m o ili a t io n

33

6

p p e r e t re m it ra d ia l n e r ve Static volar wrist hand splints D nam ic splints Te node sis splints Patie nt outcom e s and patie nt pre fe re nce s

33

o e r e t re m it

fi u la r n e r ve

i

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In t ro d u ct io n

35

Co m p lica t io n s

36

Su m m a r

36

e fe re n ce s

3

u r t e r re a d in g

3

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Ne rve in urie s

3

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Author Endre arga

Dagu m recogn ized th is, statin g th at “th e qu estion o h ow lon g to im m obilize an extrem ity, an d h en ce a n erve, a ter repair h as n ever been properly addressed” [1]. For exam ple, digital n erve in ju ries in th e h an d are requ en t an d can resu lt in sign i can t im pairm en t an d u n ction al restriction . Despite th is, on ly a relatively sm all n u m ber o papers are devoted to th is topic, particu larly w ith respect to postoperative reh abilitation . Splin tin g a ter repair, w ith th e idea to protect th e repaired n erve rom excessive stretch in g, is still com m on ly u sed. Stu dies o an atom ical specim en s in dicate postoperative reh abilitation is n ot n ecessary w ith resection s o u p to 2.5 m m [2]. A ran dom ized con trolled trial w as u n dertaken to determ in e w h eth er splin tin g a ter isolated th -degree digital n erve tran section w as in act requ ired [3]. Tw en ty six su bjects w ere recru ited over a 2-year period an d ran dom ized to eith er 3 w eeks o h an d-based splin tin g or ree active m otion . An alysis o covarian ce in dicated n o di eren ces in sen sitivity at 6 m on th s betw een th e tw o grou ps. Su bjects also reported th eir greatest u n ction al lim itation s w ere becau se o h yperesth esia [3]. Alth ou gh th is stu dy is u n derpow ered, th ese lim ited resu lts su ggest splin tin g m ay n ot be obligatory postoperatively. In gen eral, h ow ever, splin ts an d casts are applied to in ju red lim bs to su pport an d protect bon es an d so t tissu e. Th e cast h elps to redu ce pain , sw ellin g, an d m u scle spasm s ollow in g th e in ju ry. I a bon e is ractu red, a cast or splin t can be u sed

n i e d

Nerve in ju ry in volves dam age to th e n ervou s tissu e, an d periph eral n erve in ju ries are a m ajor con tribu tor o ch ron ic disability. In recen t decades, sign i can t tim e an d resou rces h ave been spen t to m ake progress in n erve repair tech n iqu es an d to in ven t tools to assist in th e diagn osis an d m appin g o n eu ral in ju ry. Th is can n ot be said, h ow ever, o th e resou rces in vested in research in g reh abilitation strategies a ter n eu rorrh aph y (n erve su tu re). Th ere are also con troversial topics su ch as th e tim in g o n erve repair.

to stabilize th e ractu re. I a n erve h as also been in ju red an d su rgically repaired, th e cast h olds th e join t in an appropriate position in order to avoid su tu re ten sion . Follow in g th e su tu re o a lacerated n erve, casts gen erally rem ain in place u n til n erve h ealin g h as occu rred (typically 3–6 w eeks).

i

In t ro d u ct io n

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Nerve in uries

ia gn o s t ics

In assessin g or a poten tial n erve in ju ry, accu rate diagn osis o n erve in ju ry type can be di cu lt. I th e in ju ry is open , di eren tial diagn osis is easy becau se th e de n itive n erve in ju ry is eviden t. How ever, w ith closed n erve in ju ries (eg, blu n t in ju ries, cru sh in g) th e correct im m ediate diagn osis is m u ch m ore di cu lt. Regu lar observation an d electrodiagn ostic tests, su ch as a n erve con du ction stu dy, cou ld be requ ired. le ct ro d ia gn o s t ic t e s t s

A n erve con du ction stu dy (NCS) is a diagn ostic test requ en tly u sed to evalu ate th e u n ction o th e m otor an d sen sory n erves, prin cipally u sin g electrical con du ction . Nerve con du ction velocity is a com m on m easu rem en t m ade du rin g th is test. Th e term n erve con du ction velocity (NCV) is o ten u sed to m ean th e actu al test, bu t th is can be m isleadin g, sin ce velocity is on ly on e m easu rem en t in th e test su ite. For th e m otor n erves, n erve con du ction stu dies are perorm ed by electrical stim u lation o a periph eral n erve an d recordin gs rom a m u scle su pplied by th is n erve. Th e tim e it takes or th e electrical im pu lse to travel rom th e stim u lation to th e recordin g site is m easu red. Th is valu e is called th e laten cy, an d is m easu red in m illisecon ds (m s). Th e size o th e respon se, called th e am plitu de, is also m easu red. Motor am plitu des are m easu red in m illivolts (m V). By stim u latin g tw o or m ore di eren t location s alon g th e sam e n erve, th e NCV can be determ in ed across di eren t segm en ts. Calcu lation s are per orm ed u sin g th e distan ce betw een th e di eren t stim u latin g electrodes an d th e di eren ce in laten cies.

3

Ne rve in urie s

3

T p e s o f p e rip e ra l n e r ve in u rie s

i

d

e

i

n

e

Sen sory NCS are per orm ed by electrical stim u lation o a periph eral n erve an d recordin gs rom a pu rely sen sory portion o th e n erve, su ch as on a n ger. Like th e m otor stu dies, sen sory laten cies are on th e scale o m illisecon ds. Sen sory am plitu des are m u ch sm aller th an th e m otor am plitu des, u su ally in th e m icrovolt (µV) ran ge. Th e sen sory NCV is calcu lated based u pon th e laten cy an d th e distan ce betw een th e stim u latin g an d recordin g electrodes.

Periph eral n erves ( ig can su er in ju ry in a variety o w ays, an d th ese in ju ries are classi ed as bein g on e o th e ollow in g th ree types [4]: • Neu rapraxia • Axon otm esis • Neu rotm esis. Neu rapraxia is th e least orm o n erve in ju ry w h ere th ere is tem porary or in com plete in terru ption o n erve tran sm ission dow n th e n erve ber. Th e n erve an d sh eath rem ain in tact an d com plete recovery is expected. Axon otm esis is a m ore seriou s in ju ry an d exists w h en th e axon n erves an d th e m yelin sh eath s are in ju red bu t th e epin eu riu m , en don eu riu m , an d perin eu riu m are in tact. Axon otm esis is u su ally th e resu lt o a m ore severe cru sh or con tu sion th an n eu ropraxia, bu t can also occu r w h en th e n erve is stretch ed (w ith ou t dam age to th e epin eu riu m ). Regen eration occu rs over w eeks to years. Neu rotm esis is th e m ost severe lesion w ith a m u ch sm aller poten tial or recovery as th e n erve an d n erve sh eath are com pletely in terru pted. It occu rs ollow in g severe con tu sion , stretch in g, an d laceration in ju ries. Both th e axon an d en capsu latin g con n ective tissu e lose th eir con tin u ity. Den ervation ch an ges recorded by NCS are th e sam e as th ose seen w ith axon otm etic in ju ry. Th ere is a com plete loss o m otor, sen sory, an d au ton om ic u n ction . I th e n erve h as been com pletely divided, axon al regen eration cau ses a n eu rom a to orm in th e proxim al stu m p. Wh ile th e progn osis can o ten be good or sign i can t or com plete recovery or th e rst tw o n erve in ju ry categories, com plete in terru ption rarely ach ieves com plete retu rn o sen sation an d m otor u n ction [5]. Im m obilization is typically u sed a ter repair o a n eu rotm esis, bu t it can also be h elp u l or patien ts w ith n eu rapraxias or axon otm eses.

3

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Pro t e ct io n o f n e r ve s fro m t e n s io n

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P

s io lo gic lim it s

Wh en n erves are elon gated w ith in ph ysiologic (n orm al) lim its, adequ ate n eu ral blood f ow is m ain tain ed, bu t on ly u p to th e poin t w h ere th e n orm al vascu lar protective m ech an ism s are preserved. Main ten an ce o in tran eu ral blood f ow du rin g n eu ral elon gation is accom plish ed by th e blood vessels in n erves con tain in g u n du lation s an d coils. Wh en n erves are loose, th ese vascu lar con volu tion s are accen tu ated. How ever, i th e n erve is len gth en ed, th e vascu lar coils ollow th e n erve elon gation an d are pu lled tau t. Fu rth erm ore, th e lu m en (in tern al space) o th e vessels is redu ced an d occlu sion (blockage) can occu r, particu larly w h en th e n erve is stretch ed beyon d th e lim it o protection [6]. Th e blood vessels are th en stran gled, in tran eu ral blood f ow is com prom ised, an d n erve u n ction deteriorates [7]. I th e stretch is taken on ly sligh tly beyon d th e protective lim its, an d or a brie period, n erve u n ction is likely to rapidly retu rn to n orm al [8]. How ever, i th e strain in th e n erve is particu larly severe or su stain ed, th e alteration s in n erve u n ction w ill be perm an en t. Th e relevan ce o in tran eu ral blood f ow is th at excessive m ech an ical stress can cau se an oxia an d n erve dam age, leadin g to h eigh ten ed m ech an osen sitivity an d pain . In th ese circu m stan ces, m ovem en ts th at m ech an ically stress th e n eu ral tissu es m ay evoke sym ptom s. 1 3 3 4 7 5

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ig Pe riphe ral ne rve anatom Axon M e lin she ath Endone urium Pe rine urium ascicle Epine urium Intrane ural blood ve sse ls

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Author Endre arga

Th e ten sion placed on a n erve also depen ds on th e n erve’s location an d th e join t position . For exam ple, a radial n erve is relaxed by elbow f exion bu t th e posteriorly located u ln a n erve is stretch ed by elbow f exion an d relaxed by elbow exten sion . Im m obilization u sin g casts, splin ts, or orth oses tem porarily places th e lim b in to a position th at avoids stretch in g th ose repaired n erves u n til th e repair can w ith stan d th e u su ally applied orces.

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In d ica t io n s fo r p re o p e ra t ive a n d p o s t o p e ra t ive im m o ili a t io n

Im m obilization ban dages are in dicated in th e treatm en t o n erve in ju ries or a variety o reason s, an d are ideal or h elpin g to ach ieve th e ollow in g goals [10]: • To keep su rgically repaired n erve(s) lim p in order to preven t ten sion th at cou ld in ter ere w ith n erve h ealin g at th e su tu re site • To avoid join t position s/ m otion s th at cou ld aggravate a com pressed n erve • To redu ce pain an d paresth esia cau sed by n erve en trapm en t • To im prove h an d dexterity by com pen satin g or w eak/ paralyzed m u scles • To avoid overstretch in g o den ervated m u scles • To preven t sh orten in g o u n opposed in n ervated m u scles • To preven t join t con tractu res • To retain ten don an d n erve glide • To perm it join t m otion in order to optim ize join t cartilage n u trition an d h ealth • To preven t th e developm en t o m aladaptive com pen satory/ su bstitu tion preh en sion pattern s.

p p e r e t re m it

ra d ia l n e r ve

Orth otic in terven tion , casts, or splin tin g or radial n erve paralysis sh ou ld deal w ith both th e u n ction al (occu pation al) n eeds o th e patien t an d biological n eeds o th e tissu e. 6

St a t ic vo la r

ris t

a n d s p lin t s

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A static volar w rist-h an d splin t (see ch apters 15.8 Palm ar sh ort arm splin t u sin g plaster o Paris; 15.9 Palm ar sh ort arm splin t u sin g syn th etic; an d 15.19 Palm ar sh ort arm splin t in clu din g th e n gers u sin g plaster o Paris) is com m on ly provided or n igh t u se to optim ally position th e w rist, th u m b, an d n gers an d to preven t con tractu res. For daytim e u n ction , variou s orth otic design s h ave been docu m en ted. Th ey vary accordin g to th e orce system u sed (static, dyn am ic, or ten odesis) an d to th e n u m ber o join ts in corporated: • Wrist on ly (see ch apters 15.8 Palm ar sh ort arm splin t u sin g plaster o Paris; 15.9 Palm ar sh ort arm splin t u sin g syn th etic) • Wrist an d n gers (15.19 Palm ar sh ort arm splin t in clu din g th e n gers u sin g plaster o Paris) • Wrist, n gers, an d th u m b (15.13 Th u m b spica splin t u sin g plaster o Paris; 15.14 Th u m b spica splin t u sin g syn th etic) • Fin gers an d th u m b.

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Du rin g th e early ph ase o h ealin g, it is im portan t to protect a su tu red n erve rom ten sile stress. Repairin g n erves u n der sign i can t ten sion is u n desirable an d axon al con du ction an d n eu ral regen eration can be placed at risk. In tran eu ral h em orrh age rom su tu re-lin e ten sion in vites scar tissu e to occu r betw een th e n erve en ds. Matu rin g scar tissu e can sh rin k an d con strict th e n erve bers an d, th ere ore, retard axon al m atu ration an d preven t proper m yelin ation . Lu n dborg stated “sligh t ph ysiologic ten sion (in traoperatively) is probably n o disadvan tage, as lon gitu din ally orien ted stress lin es m ay provide u se u l con tact gu idan ce to th e advan cin g axon s” [9].

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Static splin ts m ain tain th e w rist alon e an d can be volar (see ch apters 15.8 Palm ar sh ort arm splin t u sin g plaster o Paris; 15.9 Palm ar sh ort arm splin t u sin g syn th etic), dorsal (15.10 Dorsal sh ort arm splin t u sin g syn th etic), or circu m eren tial (15.11 Sh ort arm cast u sin g plaster o Paris; 15.12 Sh ort arm cast u sin g syn th etic, com bicast tech n iqu e). Th ey can be eith er cu stom -m ade or pre abricated.

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n a m ic s p lin t s

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Dyn am ic splin ts u se en ergy-storin g m aterials, su ch as elastic, sprin gs, or sprin g w ire, to pu ll a ected join t(s) in on e direction w h ile allow in g active-resisted m ovem en t in th e opposite direction o th e dyn am ic orce [11]. Th e m ost com m on ly provided orth otic design or h igh or in term ediate radial n erve paralysis is com posed o a static su pport or th e w rist (across th e palm ar arch ), w h ereas th e n gers an d th u m b h ave dyn am ic exten sion assists via cu s arou n d th e proxim al ph alan ges. Oth er design s provide dyn am ic exten sion assistan ce to th e n gers, th u m b, an d w rist.

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Th e provision o dyn am ic exten sion pow er gen erally requ ires an ou trigger, orm ed eith er rom w ire or th erm oplastic th at projects above th e dorsal su r ace o th e h an d or th e n gers an d above th e radial su r ace or th e th u m b. Con stru ction o su ch an ou trigger o ten requ ires ardu ou s w ire cu ttin g an d ben din g an d very secu re attach m en t to th e dorsal orearm base.

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Te n o d e s is s p lin t s

Ten odesis splin ts h arn ess active w rist f exion to create passive n ger m etacarpoph alan geal join t exten sion an d con versely h arn ess active m etacarpoph alan geal (MCP) join t f exion in order to produ ce passive w rist exten sion . An advan tage o ten odesis splin ts over dyn am ic splin ts is th at m etal ten odesis com pon en ts closely ollow th e con tou rs o th e h an d, th u s takin g u p less space. How ever, th e draw backs are: • Th e n ger MCP join ts f ex or exten d as a u n it, th u s in depen den t MCP join t m otion is n ot possible • Th e th u m b is o ten exclu ded u n less a separate dyn am ic com pon en t is added • Th e en tire w eigh t o th e h an d is su spen ded by cu s arou n d th e proxim al n ger ph alan ges, w h ich can be tirin g w h en con tin u ou sly in u se du rin g th e day. High -level an d in term ediate-level radial n erve in ju ries requ ire a orearm -based splin t becau se th e w rist n eeds su pport. A low -level in ju ry in volvin g on ly th e posterior in terosseu s n erve (th e deep m otor bran ch o th e radial n erve) m igh t n ot requ ire w rist su pport/ assistan ce. A h an d-based design providin g dyn am ic n ger an d th u m b exten sion assistan ce cou ld be adequ ate. Correspon din gly, in a h igh -level in ju ry w h en th e radial n erve h as regen erated su cien tly to restore w rist exten sion pow er, a h an d-based design can be su bstitu ted or a orearm -based design . Man y patien ts w ith h igh radial n erve palsies n d th at a sim ple sh ort arm splin t th at h olds th e w rist dorsif exed perm its airly u n ction al u se o n gers w ith less en cu m bran ce th an eith er a dyn am ic or a ten odesis splin t ( ig ) (see ch apter 15.8 Palm ar sh ort arm splin t u sin g plaster o Paris; an d 15.9 Palm ar sh ort arm splin t u sin g syn th etic).

b

ig a In a palm ar short arm splint, the carpus and m e ta carpus on the palmar side of the wrist are supporte d, which can he lp tre at ne rve pals

34

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Author Endre arga

Th ree stan dardized u n ction al ou tcom e m easu res statistically sh ow ed th at both th e dyn am ic an d ten odesis splin ts en abled con siderably im proved h an d u n ction , w h ereas th e static volar w rist splin t did n ot. Wh en given th e ch oice, on e em ale patien t at n o stage u sed th e ten odesis splin t. Sh e w ore th e static volar w rist splin t m ore o ten th an th e dyn am ic splin t becau se it provided su pport an d w as less eviden t. Th u s, som e patien ts seem to pre er to sacri ce better h an d u n ction in avor o w earin g a splin t th at draw s less atten tion .

fi u la r n e r ve

Fibu lar n erve m al u n ction cou ld stem rom disc h ern iation , pelvic ractu res, acetabu lar ractu res, kn ee dislocation s, open in ju ries, an d com pression [14]. It is im portan t to keep in m in d th at an in appropriate cast can itsel be a cau se o bu lar n erve dam age. Care m u st be taken to ash ion a properly m olded cast, especially n ear th e bu lar-h ead region .

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Fibu lar n erve palsy does n ot alw ays resolve spon tan eou sly; i it is le t u n treated, th e loss o dorsif exion o th e an kle an d persisten t paresth esias can resu lt in severe u n ction al disability. Th ere ore, i n on operative im m obilization does n ot lead to im provem en t w ith in 2 m on th s, operative decom pression m igh t n eed to be con sidered [15].

e

Han n ah an d Hu dak con du cted a sin gle-su bject stu dy on a patien t th at h ad su stain ed a su bglen oid sh ou lder dislocation [12]. A ter a brach ial plexopath y, sh e experien ced u ll recovery o th e biceps, triceps, su pin ator, an d pron ator-teres m u scles bu t residu al im pairm en ts in clu ded lack o w rist, n ger, an d th u m b exten sion (ie, radial n erve palsy). Th eir stu dy exam in ed h an d u n ction an d patien t pre eren ce, com parin g th ree orth otic design s: • Static volar w rist • Dorsal orearm -based dyn am ic n ger an d th u m b MCP join t assistive exten sion • Dorsal orearm -based ten odesis w ith dyn am ic th u m b assistive exten sion .

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Pa t ie n t o u t co m e s a n d p a t ie n t p re fe re n ce s

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In ch ron ic bu lar n erve palsy, an orth osis or splin t m ay be in dicated (see ch apters 16.10 Dorsal sh ort leg splin t u sin g plaster o Paris; an d 16.11 Dorsal sh ort leg splin t u sin g syn th etic) in order to li t th e ore oot an d avoid stu m blin g.

Alsan cak explored satis action am on g 83 su bjects w ith radial n erve in ju ry th at w ere tted w ith dorsal dyn am ic w risth an d splin ts [13]. All patien ts w ere very h appy w ith th e su pport, u n ction ality, an d ease o takin g on an d o , bu t w ere dissatis ed w ith th e appearan ce u n til th e design w as m odi ed to a low er-pro le, m ore ration alized style, w h ich tted m ore closely to th e h an d.

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Su m m a r

Com partm en t syn drom e is particu larly h ard to recogn ize in patien ts w ith periph eral n erve in ju ries as severe pain is typically absen t, an d th e progressive im pairm en t o sen sation an d m otor u n ction m igh t already exist w h en th e patien t presen ts. It is also on e o th e m ost seriou s com plication s ollow in g an in appropriately applied cast an d can occu r w h en a cast is too tigh t. As th e a ected lim b sw ells, th e cast acts as a closed com partm en t, tigh tly com pressin g both n erves an d blood vessels. Com partm en t syn drom e can cau se perm an en t n erve dam age or loss o lim b du e to decreased circu lation an d oxygen su pply to th e tissu es.

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Patien ts sh ou ld be in stru cted to call th e ph ysician at on ce i on e or m ore o th e ollow in g sign s or sym ptom s appear: • In creased pain com bin ed w ith th e eelin g th at th e cast is too tigh t • Nu m bn ess an d tin glin g in th e h an d or oot, or an in ability to actively m ove th e n gers or toes • Bu rn in g an d stin gin g sen sation s • Extrem e sw ellin g o th e lim b below th e cast • Progressive im pairm en t o sen sation an d m otor u n ction .

36

• Nerve in ju ries in volve dam age to th e n ervou s tissu e an d are a m ajor con tribu tor o ch ron ic disability • Nerve in ju ries are classi ed in to th ree types: n eu rapraxia, th e least severe orm o in ju ry, w h ere th e stru ctu re o th e n erve rem ain s in tact; axon otm esis, th e resu lt o a m ore severe cru sh in ju ry, con tu sion , or stretch in ju ry, w h ere regen eration occu rs over w eeks to years; an d n eu rotm esis, th e m ost severe lesion , w ith axon an d con n ective tissu e losin g con tin u ity, resu ltin g in com plete loss o u n ction • Wh en n erves are recoverin g rom in ju ry or treatm en t, im m obilization u sin g casts, splin ts, or orth oses tem porarily places th e lim b in to a position th at avoids stretch in g th e repaired n erves, u n til th e repair can w ith stan d th e u su ally applied orces • Non operative an d postoperative treatm en t or radial n erve in ju ries in clu de static splin ts (to h elp preven t con tractu res), dyn am ic splin ts (u sin g en ergy-storin g m aterials su ch as elastic or sprin gs), an d ten odesis splin ts (allow in g w rist an d MCP join t m ovem en t) • Non operative treatm en t u sin g casts an d splin ts can also be in dicated or bu lar n erve in ju ries o th e low er extrem ity • Com partm en t syn drom e is a seriou s poten tial com plication ollow in g an in appropriately applied cast, occu rrin g w h en a cast is too tigh t, com pressin g both n erves an d blood vessels.

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Author Endre arga

e fe re n ce s

12.

13.

14.

i al o

, o r a c e r B,

c ra t

repair. Scand J Surg. 2008; 97(4):310 –316. ess

,

e t t le

S, P ilip s C , e t a l Hand

and Upper Extremity Splinting: Principles and Methods. 3rd ed. St Lou is: Elsevier Mosby; 2005. Periph eral Nerve In ju ries. Cam eron M H, Mon roe LG (eds). Physical Rehabilitation: Evidence-Based Examination, Evaluation, and Intervention. St Lou is: Sau n ders Elsevier; 2007:473 –513. i son

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11.

a lin B Tech n iqu es o periph eral n er ve

n

10.

Neu rotropism , rozen mu scle gra ts an d oth er con du its. J Hand Surg Br. 1991 Dec; 16(5):473 –476. p fe l , Siga fo o s T. Com parison o ran ge-o -m otion con strain ts provided by splin ts u sed in th e treatm en t o cu bital tu n n el syn drom e – a pilot stu dy. J Hand Ther. 20 06 Oct–Dec; 19(4):38 4 – 392. Pa rr CB, a rp e r , le t c e r I, e t a l . New types o lively splin ts or periph eral n er ve lesion s a ectin g th e h an d. Hand. 1970 Mar; 2(1):31–38. a n n a S , u d a P Splin tin g an d rad ial n er ve palsy: a sin gle-su bject experim en t. J Hand Ther. 2001 Ju l–Sep; 14(3):195 –201. ls a n ca S Splin t satis action in th e treatm en t o trau m atic rad ial n erve in ju ries. Prosthet Orthot Int. 20 03 Au g; 27(2):139 –145. u n d o rg

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regen eration , repair an d gra tin g. J Hand Ther. 1998; 11(2):111–117. 2. C a o P, Bra u n , Ta T, e t a l . Early passive m obilization a ter d igital n erve repair an d gra tin g in a resh cadaver m odel. Plast Reconstr Surg. 2001; 108(2):386 –391. 3. ip o n d N, Ta lo r , id e r . Postoperative splin tin g or isolated d igital n erve in ju ries in th e h an d. J Hand Ther. 20 07 Ju l–Sep; 20(3):222–231. 4. Se d d o n . Classi cation o n erve in ju ries. Br Med J. 1942 Au g 29; 2(4260):237–239. 5. o rd e m ve n n e T, a n ge r , c m a n S, e t a l . Lon g-term resu lts a ter prim ary m icrosu rgical repair o u ln ar an d m ed ian n erve in ju ries: a com parison o com m on score system s. Clin Neurol Neurosurg. 2007 Apr; 109(3):263 –271. 6. u n d o rg , d e vi B. E ects o stretch in g th e tibial n erve o th e rabbit. A prelim in ary stu dy o th e in tran eu ral circu lation an d th e barrier u n ction o th e perin eu riu m . J Bone Joint Surg Br. 1973 May; 55(2):390 –401. 7. ga t a , Na it o . Blood f ow o periph eral n er ve e ects o d issection , stretch in g an d com pression . J Hand Surg Br. 1986 Feb; 11(1):10 –14. 8. u n d o rg , e l e rm a n , in t e e r Co n ve r , e t a l . Med ian n erve com pression in th e car pal tu n n el – u n ction al respon se to exper im en tally in du ced con trolled pressu re. J Hand Surg Am. 1982 May; 7(3):252–259.

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B. Periph eral n erve

c e e P, Ngu e n C Cu stom ized dyn am ic

d

a gu m

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u r t e r re a d in g

splin tin g: orth oses th at prom ote optim al u n ction an d recovery a ter rad ial n erve in ju ry: a case report. J Hand Ther. 2007 Jan –Mar; 20(1):73 –88.

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Tran sien t peron eal n erve palsies rom in ju ries placed in traction splin ts. Am J Emerg Med. 1999 Mar; 17(2):160 – 162. 15. o n t , e llo n , C e n , e t a l . Th e operative treatm en t o peron eal n erve palsy. J Bone Joint Surg Am. 1996 Ju n ; 78(6):863 –869.

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Author Mate Cime rman

Indications for nonoperative treatment of infections Mate Cime rman

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Author Mate Cime rman

Pa t o ge n e s is

Osteom yelitis can be on e o tw o types, depen din g on its sou rce o in ection : • Hem atogen ou s, w h en it origin ates rom bacterem ia in th e blood • Con tigu ou s, w h en it origin ates rom an in ection o n earby tissu e. Hem atogen ou s osteom yelitis m ain ly occu rs in ch ildren , bu t can also be ou n d am on g th e adu lt popu lation . In ch ildh ood, th e m etaph ysis o lon g bon es (tibia an d em u r) is m ost requ en tly in volved. Hem atogen ou s in ection starts in th e m etaph ysis an d is cau sed by m icroin arction in th e m etaph yseal-epiph yseal ju n ction w h ere n u trition al blood f ow is relatively poor. Th e in ciden ce o acu te h em atogen ou s osteom yelitis in ch ildren h as n ot varied over recen t decades. A sin gle in ection is m ost com m on , an d staph ylococcu s au reu s rem ain s th e m ain organ ism cau sin g it [2].

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In f am m ation o bon e is called “osteitis” an d in ection o th e bon e ch an n el is classically called “osteom yelitis”. Th e root w ords osteon (bon e) an d m yelo (m arrow ) are com bin ed w ith itis (in f am m ation ). Th e term w as rst u sed by th e Fren ch su rgeon Edu ard Ch assaign ac in 1852 [1], w h o de n ed th e disease as an in f am m atory process accom pan ied by bon e destru ction an d cau sed by an in ectin g m icroorgan ism . Th is de n ition still applies today. Th e septic in f am m ation o th e join t is called “septic arth ritis”. Osteom yelitis is a com plex disease an d can di er w ith regard to du ration , etiology, path ogen esis, exten t o bon e in volvem en t, an d th e type o h ost th e respective patien t represen ts. Despite n ew diagn ostic tools, operative tech n iqu es, an d an tim icrobial agen ts, it rem ain s di cu lt to treat an d th e con sequ en ces can be devastatin g.

In con tigu ou s osteom yelitis, th e path ogen ic organ ism is eith er directly in ocu lated in to th e bon e by th e trau m a itsel (open ractu res), by su rgery (in tern al xation o ractu res), or reach es th e bon e rom adjacen t in ected so t tissu e (especially in cases o gen eralized vascu lar in su cien cy an d diabetes). Th e bacteriology in con tigu ou s in ection is m ore diverse, bu t in th is type o osteom yelitis, staph ylococcu s au reu s is also th e m ost com m on an d im portan t m icroorgan ism [3]. Th e in ciden ce o osteom yelitis du e to direct in ocu lation is in creasin g [4]. Th is is probably du e to th e risin g n u m ber o h igh -en ergy ractu res an d th e in creasin g u se o orth opedic xation devices.

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In t ro d u ct io n

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Indications for nonoperative treatment of infections

Acu te osteom yelitis is a su ppu rative in ection o th e bon e, accom pan ied by edem a, vascu lar con gestion , an d sm allvessel th rom bosis. On ce th e in f am m ation progresses, vascu lar su pply to th e bon e decreases an d th e in ection w ill also exten d in to th e su rrou n din g so t tissu e. On ce areas o dead bon e are orm ed (sequ estra), th e disease becom es ch ron ic an d is di cu lt to treat an d eradicate. Th ere ore, acu te osteom yelitis sh ou ld be treated as soon as possible in order to preven t th e orm ation o dead bon e an d th e progression to its ch ron ic orm . In th e path ogen esis o bon e in ection , it is very im portan t to u n derstan d th e role o bio lm . Som e im portan t m icroorgan ism s in bon e in ection , in clu din g staph ylococcu s au reu s, epiderm idis, streptococci, an d pseu dom on as aeru gin osa, grow as bio lm s. Bio lm is a h igh ly stru ctu red h eterogen eou s com m u n ity o sessile bacteria su rrou n ded by h ydrated extracellu lar m atrix attach ed to a su r ace o in ert m aterial (im plan t) or n on vital bon e. Th e ch aracteristics o bio lm bacteria m ake th em di cu lt to eradicate. Th is derives rom a com bin ation o ph en otypic, m ech an ical, an d m etabolic m ech an ism s. For exam ple, th e sessile m icroorgan ism s w ith in a bio lm are u p to 1,000 tim es m ore resistan t to an tim icrobial agen ts th an th eir ree-livin g (plan kton ic) cou n terparts [5]. An oth er w ay in w h ich bacteria elu de h ost de en ses an d cau se bon e in ection is by gain in g access to th e in terior o th e cell. Th is w as dem on strated w ith staph ylococci in h u m an osteoblasts an d osteocytes as w ell as in vitro [6].

4

Indications for nonope rative tre atme nt of infe ctions

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s ica l e a m in a t io n

Ch ildren w ith h em atogen ou s osteom yelitis m ay presen t w ith acu te sign s o in ection in clu din g ever, leth argy, pain , an d local sign s o in ection . In older ch ildren , pain is m ore localized an d th e ch ild re u ses to bear w eigh t. Norm al body tem peratu re does n ot exclu de osteom yelitis [7]. In con trast, adu lts w ith h em atogen ou s osteom yelitis presen t w ith vagu e sym ptom s con sistin g o n on speci c pain an d a low -grade ever over a period o 1–3 m on th s. Patien ts w ith con tigu ou s or posttrau m atic osteom yelitis m ay presen t w ith localized bon e an d join t pain , eryth em a, sw ellin g, an d drain age arou n d th e site o trau m a or su rgery. Sign s o bacterem ia su ch as ever, ch ills, an d n igh t sw eats m ay be presen t in th e acu te ph ase, bu t n ot in th e ch ron ic ph ase. Both h em atogen ou s an d con tigu ou s osteom yelitis can progress to a ch ron ic in ection . Th is can o ten presen t w ith pain , ch ron ic skin ch an ges, pu ru len t drain age th rou gh stu las, sequ estration , an d possible in stability. Wh en th is occu rs, diagn osis is easy bu t treatm en t w ill be m u ch m ore di cu lt th an i in ection is ou n d early. 3

a o ra t o r s t u d ie s

3 3 3 3

Wh ite blood cell cou n t (WBC) m ay be elevated w ith acu te in ection bu t is o ten n orm al w ith ch ron ic osteom yelitis. Eryth rocyte sedim en tation rate (ESR) is u su ally elevated both in acu te an d ch ron ic osteom yelitis an d decreases a ter su ccess u l treatm en t. Th e ESR is a sen sitive bu t n on speci c m easu re o in f am m ation becau se it can be in f u en ced by n u m erou s actors su ch as age, f u id disbalan ce, n u trition al statu s, an d h orm on al disorders. Th e patien t’s ESR also rises a ter m ajor operative procedu res an d retu rn s to n orm al w ith in m on th s. Th e level o C-reactive protein (CRP) also rises in acu te an d ch ron ic osteom yelitis. It is an “acu te-ph ase” reactan t, risin g w ith in 6 h ou rs in respon se to tissu e dam age an d in f am m ation , an d th en decreasin g rapidly. A tran sien t rise in th e level o CRP is seen a ter su rgery, w ith its peak at abou t 2 days, an d declin e over th e n ext ew days, reach in g its baselin e by 3 w eeks. I th e ESR an d CRP levels retu rn to n orm al du rin g th e cou rse o treatm en t it is a avorable progn ostic sign , bu t in com prom ised h osts, th ese laboratory valu es are n ot reliable becau se th ese patien ts are con stan tly ch allen ged by oth er illn esses an d periph eral lesion s th at can elevate th ese in dices as w ell [8].

Im a gin g ra s

Con ven tion al x-rays rem ain th e basic in itial im agin g tech n iqu e an d sh ou ld be m ade w h en ever acu te or ch ron ic osteom yelitis is su spected becau se th ey are sim ple, econ om ical, easily available, an d u su ally e ective. Th e x-rays sh ou ld be scru tin ized or th e ollow in g: • Discrete periosteal elevation • En dosteal scallopin g • Areas o dem in eralization • Hardw are loosen in g. Ph ysician s sh ou ld be aw are th at th ese ch an ges occu r relatively later, a ter th e on set o osteom yelitis an d are n ot seen du rin g th e rst 2 w eeks. 3 3

Basic laboratory tests th at sh ou ld rou tin ely be obtain ed in cases o su spected osteom yelitis in clu de: • Wh ite blood cell cou n t • Eryth rocyte sedim en tation rate • C-reactive protein .

4

Alth ou gh n ot rou tin ely u sed, th e seru m -procalciton in level can be a h elp u l diagn ostic m arker in order to di eren tiate in ectiou s rom n on in ectiou s ever m ore reliably a ter orth opedic su rgery [9]. Fu rth er laboratory tests sh ou ld be requ ested in order to m on itor th e system ic an d local statu s o th e patien t.

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Magn etic reson an ce im agin g sh ou ld be requ ested i th e diagn osis is dou bt u l. Magn etic reson an ce im agin g (MRI) is especially u se u l in th e diagn osis o h em atogen ou s osteom yelitis in ch ildh ood, distin gu ish ed by h igh sen sitivity an d speci city w ith n o radiation bu rden . I an MRI is n ot easible du e to th e presen ce o h ardw are, bon e scin tigraph y sh ou ld be per orm ed. 3 3 3 CT s ca n a n d P T

Addition al im agin g in clu des com pu ted tom ograph y an d positron em ission tom ograph y. Com pu ted tom ograph y (CT) scan s can be u sed to h elp establish a su rgical plan both or acu te an d ch ron ic osteom yelitis w ith excellen t presen tation o possible sequ estra [6] ( ig ). Positron em ission tom ograph y (PET) w ith its h igh sen sitivity an d speci city is u sed m ore requ en tly in th e diagn osis o osteom yelitis ( ig ), h ow ever, it m ay n ot be available everyw h ere. 3 4

Cu lt u re s

Iden ti yin g th e cau sative organ ism (s) o osteom yelitis is h elp u l in m akin g a de n itive diagn osis an d selectin g th e appropriate an tibiotic regim en . Specim en s or cu ltu res sh ou ld optim ally be obtain ed rom bon e or rom blood (in acu te h em atogen ou s osteom yelitis). Sin u s tract cu ltu res are gen erally u n reliable an d specim en s rom so t-tissu e aspiration

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Author Mate Cime rman

do n ot correlate w ell w ith bon e cu ltu res [10]. Wh en ever possible, cu ltu res sh ou ld be obtain ed be ore an tim icrobial th erapy h as been started. At least th ree in traoperative tissu e areas sh ou ld be sam pled an d paired or m icrobiology an d h istopath ology. Biopsies an d cu ltu res sh ou ld be repeated du rin g each su rgical procedu re u n til th e en d o th e treatm en t. In th e case o rem oved im plan ts, son ication o im plan ts is recom m en ded an d th e son ication f u id sh ou ld be cu ltu red. Th is im proves th e sen sitivity o detectin g bio lm s.

4

Cla s s ifica t io n

Th e m ost popu lar an d cu rren tly accepted classi cation or osteom yelitis w as proposed by Ciern y an d Mader [11] ( ig 3 ). It is based on th e degree o bon e in volvem en t an d on th e ph ysiological state o th e patien t or h ost. Th e classi cation com bin es ou r an atom ic stages (o th e disease) w ith th ree ph ysiological classes (o th e h ost) to de n e th e n al clin ical stage.

ig CT scan Multiplanar re construction of a chronic tibial oste om e litis with a se ue stra arrow and thic e ning and irre gularit of the tibial corte x

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Th e an atom ical stages are: Stage I • Medu llary osteom yelitis: Th e prim ary lesion is en dosteal. Hem atogen ou s osteom yelitis an d early in ection a ter in tram edu llary xation are typical exam ples. Stage II • Su per cial osteom yelitis: Th e problem is localized on th e su r ace o th e bon e. Th is is a tru e con tigu ou s ocu s lesion . Stage II, or localized osteom yelitis, is a u ll-th ickn ess lesion w ith sequ estration an d a stable bon e segm en t. Stage III • Localized osteom yelitis: It in volves th e cortical an d m edu llary bon e. Stage IV • Di u se osteom yelitis: It in volves th e en tire th ickn ess o th e bon e w ith loss o stability, as in an in ected n on u n ion .

ig a c CT and PET im age s traf c accide nt patie nt a CT scan le g AP An AP x ra of the le g including ne e and an le oint of a e ar old m ale patie nt, m onths afte r a traf c accide nt The patie nt was a pe de strian whe n rolle d ove r b a car, suffe ring grade III ope n tibia and bula fracture s, and was tre ate d with a prim ar e xte rnal xator, multiple soft tissue re vision surge rie s, followe d b a plate oste os n the sis The re we re m ultiple re vision proce dure s be cause of oste om e litis with stula at the re gion of the form e r e xte rnal xator pins This x ra was ta e n afte r partial re se ction of the tibia PET The PET positron e m ission tom ograph showing e nhance d activit in the glucose m e tabolism in m e taph sis and diaph sis as signs of oste om e litis c usion of CT and PET usion of the CT scan and the PET showing activit blac spots in the diaph sis and the m e taph sis of the tibia oste om e litis In the re se ction of the tibia, followe d b callus distraction using an Ili arov de vice , the pathologist found active oste om e litis with stula

43

Indications for nonope rative tre atme nt of infe ctions

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Th is system in clu des all types o osteitis, in clu din g septic arth ritis, by w h ich a septic join t is classi ed as su per cial osteom yelitis (osteoch on dritis). Th e h ost is classi ed as eith er type A, B, or C: Type A h ost • Th e patien t sh ow s a n orm al ph ysiological respon se to in ection an d th erapy. Type B h ost • Th e patien t is com prom ised eith er locally (type BL) or system ically (type BS). Type C h ost • Wh en ever th e treatm en t o th e disease is m ore com prom isin g or th e patien t th an th e disability cau sed by osteom yelitis itsel , th e patien t is classi ed as a type C h ost.

Th is classi cation is o great valu e or preoperative plan n in g an d or com parison o clin ical resu lts.

5

Tre a t m e n t

Com plete u n derstan din g o th e exten t o th e disease as w ell as th e n atu re o th e h ost is n ecessary be ore an y decision s can be m ade. In practice, th is m ean s com plete clin ical stagin g accordin g to Ciern y-Mader. In m ost cases, th e treatm en t sh ou ld be carried ou t as a team e ort, w ith in tern ists optim izin g h ost statu s, in ectiou s disease con su ltan ts m an agin g an tibacterial treatm en t, an d su rgeon s (orth opedic, plastic, vascu lar) addressin g an y operative treatm en ts [12]. Moreover, u n ction al im pairm en t cau sed by th e disease or recon stru ction operation s as w ell as th e m etabolic con sequ en ces o aggressive th erapy m ay in f u en ce th e selection o th e appropriate th erapy. Basic th erapy o osteom yelitis com prises th e adm in istration o an tibiotics an d su rgery [12]. Alth ou gh osteom yelitis rst o all is a disease th at is treated su rgically, m an y cases m ay in stead be treated w ith an tibiotics alon e. Acu te h em atogen ou s osteom yelitis in ch ildren sh ou ld be treated by an tibiotic th erapy. Th e treatm en t starts w ith paren teral an tibiotics, w h ich clears th e staph ylococcu s au reu s in ection , th e m ain cau sative m icroorgan ism . As soon as all in volved organ ism s are isolated, th e treatm en t sh ou ld be adju sted an d optim ized. Th e classic du ration o an tibiotic treatm en t is 4–6 w eeks [7], alth ou gh th ere is n o gen eral agreem en t on th e du ration o th erapy [7, 13]. Lim b im m obilization is an adequ ate adju van t in treatin g in ection s o bon e an d so t tissu e. A sh ort-term splin tin g o n eigh borin g join ts in th e acu te ph ase is also advisable [14]. 5

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No n o p e ra t ive t re a t m e n t

Som etim es, osteom yelitis can be treated n on operatively. Ta le o ers a su m m ary o th e advised cast treatm en t or th e variou s cases o osteom yelitis.

Oste om e litis classi cation according to Cie rn

a Stage I—Me dullar oste om e litis The infe ction is within the me dullar cavit Stage II—Supe r cial oste om e litis The infe ction is on the surface of cortical bone c Stage III— ocali e d oste om e litis ull thic ne ss cortical se ue stration, bone stabilit is m aintaine d d Stage I —Diffuse oste om e litis Circum fe re ntial le sion of the bone with im paire d stabilit

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Author Mate Cime rman

Site of infection

Nonoperati e treatment

Site of arthritis

Nonoperati e treatment

Upper arm

15.1 Long arm splint using plaster of Paris 15.2 Long arm splint using synthetic 18.3 Gilchrist bandage

Shoulder

18.3 Gilchrist bandage

Upper leg (distal)

16.5 Dorsal long leg splint using plaster of Paris

Lower leg

16.5 Dorsal long leg splint using plaster of Paris

Ankle/foot

16.10 Dorsal short leg splint using plaster of Paris 16.11 Dorsal short leg splint using synthetic

Hip

Adults: no indication Pediatric: 16.1 ne-and-a-half leg hip spica cast using plaster of Paris 16.2 Single leg hip spica cast using synthetic combicast techni ue

nee Ankle/foot

Ta le ecommended nonoperative treatments for cases of osteom elitis

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15.17 Dorsopalmar (ulnar gutter) short arm splint including two or more fingers using plaster of Paris 15.18 Dorsopalmar (ulnar gutter) short arm splint including two or more fingers using synthetic 15.19 Palmar short arm splint including the fingers using plaster of Paris

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15.6 Dorsopalmar (radial) short arm splint using plaster of Paris 15.7 Dorsopalmar (radial) short arm splint using synthetic 15.8 Palmar short arm splint using plaster of Paris 15.9 Palmar short arm splint using synthetic 15.10 Dorsal short arm splint using synthetic 15.17 Dorsopalmar (ulnar gutter) short arm splint including two or more fingers using plaster of Paris 15.18 Dorsopalmar (ulnar gutter) short arm splint including two or more fingers using synthetic 15.19 Palmar short arm splint including the fingers using plaster of Paris

15.6 Dorsopalmar (radial) short arm splint using plaster of Paris 15.7 Dorsopalmar (radial) short arm splint using synthetic 15.8 Palmar short arm splint using plaster of Paris 15.9 Palmar short arm splint using synthetic 15.10 Dorsal short arm splint using synthetic

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15.1 Long arm splint using plaster of Paris 15.2 Long arm splint using synthetic

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lbow

16.5 Dorsal long leg splint using plaster of Paris 16.10 Dorsal short leg splint using plaster of Paris 16.11 Dorsal short leg splint using synthetic

Ta le e com m e nde d nonoperative tre atm e nts in case s of acute se ptic arthritis

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cu t e s e p t ic a r t rit is

Acu te septic arth ritis is treated w ith appropriate an tibiotics an d regu lar irrigation o th e join t th rou gh a n eedle, eith er by arth roscopy or arth rotom y. Splin tin g an d im m obilization o th e join t are on ly n ecessary in acu te ph ases; early m otion is param ou n t in preservin g lon g-term join t u n ction [15]. Ta le o ers a su m m ary o th e advised cast treatm en ts in cases o acu te septic arth ritis.

An tibiotics are u su ally given in traven ou sly or 2 w eeks, ollow ed by oral adm in istration or 4 w eeks [16]. Th e su rgical treatm en t o osteom yelitis in clu des adequ ate drain age, th orou gh debridem en t, dead space m an agem en t, so t-tissu e an d bon e recon stru ction procedu res, an d stabilization , i n ecessary [6]. In Ciern y-Mader stages I, II, an d III, stabilization is n ot u su ally n ecessary. In th ese cases, a sh ort period o im m obilization o th e n eigh borin g join ts m ay be advisable or pain relie an d patien t com ort. A ter th e recon stru ction o so ttissu e de ects w ith ree f aps, 1 w eek o im m obilization in order to protect th e an astom osis is recom m en ded. Th e splin ts sh ou ld be cu stom -m ade in order n ot to com prom ise problem atic so t tissu es [17]. Th e su ggested du ration o an tibiotic treatm en t is 6 w eeks a ter im plan t rem oval or a ter th e last su rgical procedu re, an d 3 m on th s in cases o device reten tion [18]. Wh en su rgical treatm en t is n ot possible becau se o th e bad gen eral con dition s o th e patien t (type C h ost), lon g-term an tibiotic th erapy is advised.

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Indications for nonope rative tre atme nt of infe ctions

Su m m a r

• Despite m odern tech n iqu es an d n ew an tim icrobial agen ts, osteom yelitis an d oth er in ection s an d in f am m ation o th e bon es an d join ts are di cu lt to m an age • A ast an d correct diagn osis, an d iden ti cation o th e cau sative agen t(s) are o u tm ost im portan ce • Im m obilization is on e o th e m ain prin ciples in treatm en t o in ection s • In adu lts, th e prin cipal treatm en t con sists o a com bin ation o an tibiotics, su rgery, an d im m obilization

• In ch ildren , acu te h em atogen ou s osteom yelitis is treated w ith an tibiotics an d im m obilization • In developin g cou n tries, con servative m an agem en t o in ection s is o ten th e on ly treatm en t available, w h ich m ean s: an tibiotics an d im m obilization • An in terdisciplin ary approach to th e disease is h igh ly recom m en ded.

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e fe re n ce s 1. C a is s a ign a c . [Abou t osteom yelitis]. Bull Mem Soc Chir. 1852; 431–436. Fren ch . 2. u t ie rre . Bon e an d join t in ection s in ch ildren . Pediatr Clin North Am. 2005 Ju n ; 52(3):779 –794. 3. e P, a ld vo ge l . Osteom yelitis. N Engl J Med. 1997 Apr 3; 336(14):999 – 1007. 4. ille s p ie . Epidem iology in bon e an d join t in ection . Infect Dis Clin North Am. 1990 Sep; 4(3):361–376. 5. St e a rt PS, Co s t e rt o n . An tibiotic resistan ce o bacter ia in bio lm s. Lancet. 2001 Ju l 14; 358(9276):135 –138. 6. a a rin i , a d e r T, Ca l o u n . Osteom yelitis in lon g bon es. J Bone Joint Surg Am. 2004 Oct; 86-A(10):2305 – 2318. 7. e ic e r t S, S a rla n d , Cla r e N , e t a l . Acu te h aem atogen ou s osteom yelitis in ch ildren : is th ere an y eviden ce or h ow lon g we sh ou ld treat? Curr Opin Infect Dis. 20 08 Ju n ; 21(3):258 –262. 8. e P, a ld vo ge l . Osteom yelitis. Lancet. 20 04 Ju l 24 –30; 364(9431):369 – 379.

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9.

10.

11.

12.

13.

u n i e r S,

gle T, Sc u c a rd t

, e t a l.

Th e valu e o seru m procalciton in level or di eren tiation o in ectiou s rom n on in ectiou s cau ses o ever a ter orth opaed ic su rgery. J Bone Joint Surg Am. 2010 Jan ; 92(1):138 –14 8. a c o ia P , o n e s S , Sm it . Diagn ostic valu e o sinu s-tract cu ltu res in ch ron ic osteom yelitis. JA MA. 1978 Ju n 30; 239(26):2772 –2775. Cie rn 3rd , a d e r T, Pe n n in c .A clin ical stagin g system or adu lt osteom yelitis. Clin Orthop Relat Res. 2003 Sep; (414):7–24. a o N, ira n B , ip s B . Treatin g osteom yelitis: an tibiotics an d su rger y. Plast Reconstr Surg. 2011 Jan ; 127 Su ppl 1:177S–187S. P n e n , Pe lt o la . An tibiotic treatm en t or acu te h aem atogen ou s osteom yelitis o ch ild h ood: m ovin g towards sh orter cou rses an d oral ad m in istration . Int J Antimicrob Agents. 2011 Oct; 38(4):273 –280. doi: 10.1016/ j. ijan tim icag.2011.04.007. Epu b 2011 Ju n 2.

14.

ie t

, Ba c m e r

, o p p ic I.

[Osteom yelitis in ch ild ren]. Orthopade. 200 4 Mar; 33(3):287–296. Germ an . 15. o n a t t o C. Orth oped ic m an agem en t o septic arth ritis. Rheum Dis Clin North Am. 1998 May; 24(2):275 –286. 16. a t e s C , e s t o n C, o n e s , e t a l . Bacterial septic arth ritis in adu lts. Lancet. 2010 Mar; 375(9717):846 –855. 17. Ca u l e ld , a le i Ta ri i , Birc , e t a l . A n ovel splin tin g tech n iqu e to protect ree f aps in m ajor lim b trau m a. J Trauma. 2008 Mar; 6 4(3):E4 4 –4 6. 18. Tra m p u , im m e rli . Diagn osis an d treatm en t o in ection s associated w ith ractu re- xation devices. Injury. 2006 May; 37 Su ppl 2:S59 –66.

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Author Mile s rancis T Dela osa

3

Overload in uries 4

Pa t o m e c a n ics o f in u r

4

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Pre ve n t io n o f in u r

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So ft t is s u e in u rie s ittle le ague e lbow s ndrom e uadrice ps te ndonitis Osgood Schlatte r dise ase upture d Achille s te ndon e trocalcane al bursitis Dance in urie s Chronic com partm e nt s ndrom e

5

5

St re s s fra ct u re s Stre ss fracture s, m e dial tibia Stre ss fracture s of the ante rior tibial corte x Stre ss fracture s of the calcane us Stre ss fracture s of the m e tatarsals

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Mile s rancis T Dela osa

e fe re n ce s

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Ove rload in urie s

4

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Author Mile s rancis T Dela osa

Pa t o m e c a n ics o f in u r

Overload in ju ries occu r du e to excessive orce loads an d are determ in ed by su ch in trin sic actors as age, f exibility, stren gth , previou s in ju ries, an d lim b align m en t, or extrin sic actors su ch as th e en viron m en t o th e sports even t, an d speci c biom ech an ical dem an ds o th e sport. Th e n atu re o th e in ju ry im plies ch ron ic sequ elae o repetitive in su lts cau sin g a progressive in ten sity o in ju ry to th e en d organ in volved. Th ese repetitive in ju ries resu lt in local tissu e dam age in th e

e n i e d

Th e term “overload in ju ries” en com passes a spectru m o m u scu loskeletal in rm ities resu ltin g rom even ts beyon d th e ph ysiologic lim its o adaptation . Su ch ailu res are o ten th e resu lt o repetitive m icrotrau m a, w h ich explain s w h y th ey are som etim es also called “overu se in ju ries” in th e literatu re.

orm o cellu lar an d extracellu lar degen erative ch an ges. On th e cellu lar level, repetitive overload o tissu es th at ail to adapt to n ew or in creased dem an ds m ay lead to tissu e breakdow n an d overu se in ju ry. Stress or atigu e ractu res occu r w h en th e bon e does n ot adapt adequ ately to th e m ech an ical load [1]. Ph ysiologically, bon e respon ds to strain w ith rem odelin g. In overload situ ation s, th e osteoclasts rst resorb th e lam ellar bon e, cau sin g cavities, w h ich are th en re lled w ith den ser bon e by osteoblasts. Becau se o th e im balan ce betw een th e activities o osteoclasts an d osteoblasts, th e resu lt is th e w eaken in g o th e bon e, w h ich w ill ractu re. I th e load is decreased, th e bon e m ay orm den ser bon e m ass. How ever, i th e load con tin u es, th e m icrodam age resu lts in stress ractu res. On e o th e risk actors is th e existen ce o a previou s stress ractu re [2].

i

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3

Overload in uries

Failu re o adaptation is th e resu lt o an excessive load w h en execu tin g m axim al ph ysical e ort ( ig 3 ). Th ese in ju ries are gen erally seen in relation to ph ysical activity coverin g sports an d w ork-related activities o th e low er an d u pper extrem ities as w ell as th e low er back. Approxim ately 50% o all sport in ju ries are th e resu lt o overu se [1].

3

Pre ve n t io n o f in u r

Th e m ost im portan t step in in ju ry preven tion is to establish th e lim its o per orm an ce in relation to th e desired goal. Th e in trin sic risk actors m u st be con sidered, su ch as age, stren gth , an d f exibility, w h ile takin g in to accou n t th e n atu re o th e sport an d th e en viron m en t in w h ich th e sport is carried ou t. Th e n ext step is to plan a system atic process o adaptation , w h ich is re erred to as a train in g program . Th is w ill de n e th e goals o im provin g th e body ph ysiqu e to m eet th e perorm an ce level desired, sim ilar to th e w eigh t category a boxer in ten ds to com pete in [3–5].

ig 3

Training and adaptation

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Ove rload in urie s

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Th e ollow in g paragraph s ou tlin e som e o th e com m on overload related so t-tissu e in ju ries.

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Th is is a valgu s overu se syn drom e, resu ltin g rom repetitive th row in g m otion s cau sin g overload in ju ries to th e m edial elbow . A m ajor actor con tribu tin g to th is is th e lon g an d in ten se period o train in g or th ese you n g ath letes. Th e u ln ar collateral ligam en t is placed at risk, w ith in ju ries ran gin g rom an in ju ry to th e ligam en t, avu lsion o th e con dyle, to n erve com pression . Th e u se o tem porary im m obilization redu ces pain [6–9]. 4

u a d rice p s t e n d o n it is

Qu adriceps ten don itis is an overload in ju ry cau sin g in f am m ation o th e qu adriceps located at th e in sertion o th e ligam en t on top o th e patella. Th is is com m on ly ou n d in w eigh tli ters or older ath letes an d is m ain ly du e to th e h igh strain on th e m u scle du rin g th e deep squ ats. Sym ptom s presen t as con stan t pain du rin g an d a ter exercise, w h ich is at its w orst du rin g con traction o th e qu adriceps. Pain can also be elicited by applyin g an terior pressu re on th e patella, or a ter stan din g u p rom a crou ch ed position [10] ( ig 3 ).

ig 3

5

uadrice ps te ndonitis arrow

s go o d Sc la t t e r d is e a s e

Th is is a traction in ju ry o th e tibial tu bercle apoph ysis, w h ich cau ses a pain u l lu m p below th e kn ee cap n oted du rin g th e grow th -spu rts ph ase o adolescen ce. Th e in ju ry is precipitated by sports su ch as ru n n in g or ju m pin g, w h ich in f ict excessive ten sion orces on th e tibial tu bercle. Th e u n derlyin g path ology a ects th e vu ln erable epiph yseal plate, w h ich becom es in f am ed an d pron e to in ju ry [3, 7] ( ig 3 3 ). 4 4

u p t u re d

c ille s t e n d o n

Th is is a com m on in ju ry associated w ith badm in ton , squ ash , an d h igh ly dem an din g sports th at call or agility, speed, an d abru pt direction sh i ts ( ig 3 4 ). A secon d grou p com prises ath letes in volved in ru n n in g sports [1]. In ju ry o ten resu lts rom extrin sic actors su ch as im proper w arm -u p or th e u se o in appropriate ootw ear or th e playin g eld or track. Th ere are also a n u m ber o in trin sic actors th at can in f u en ce th e in ju ry: • Biom ech an ical m alalign m en t o h in d oot an d oot, eg, h yperpron ation • Varu s de orm ity o th e ore oot • In creased in version o th e h in d oot • Len gth discrepan cies o th e legs • Restricted m obility in an kle an d su btalar join t • Decreased an kle dorsif exion .

ig 3 3 Osgood Schlatter disease, commonl cause d from e xce ssive te nsion force on the tibial tube rosit arrow

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Author Mile s rancis T Dela osa

Th ere are in trin sic actors related to th e speci c dan ce regim en s. In con tem porary jazz dan ce or exam ple, in ju ries are o ten related to w eigh t an d age, an d it is th ere ore n ot recom m en ded or h eavy in dividu als [11]. Classical ballet an d tap dan cin g in ju ries typically arise rom th e exten sive am ou n t o practice, th ere ore, train in g regim en s m u st be regu lated in order to ach ieve per orm an ce goals w ith ou t cau sin g in ju ry. For classical ballet, an essen tial tech n iqu e called “tu rn ou t” requ ires th at th e kn ee an d oot are tu rn ed ou tw ard. Th is o ten resu lts in overload in ju ries in th e oot, an kle, an d m etatarsals, su ch as ten don itis an d stress ractu res [12].

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Un like acu te com partm en t syn drom es, th is is n ot a su rgical em ergen cy. It is o ten precipitated by ath letic exertion , ie, overload, an d th u s is also kn ow n as exertion al com partm en t syn drom e. It is related to repetitive ath letic m otion s like ru n n in g, bikin g, or sw im m in g. Mostly, it is observed in th e th igh an d/ or th e m edial com partm en t o th e oot. Sym ptom s can in clu de: • Cram pin g du rin g exercise • Nu m bn ess • Di cu lty in m ovin g th e oot • Occasion ally m u scle bu lgin g.

e

Retrocalcan eal bu rsitis requ en tly a ects ru n n ers an d is o ten m istaken or Ach illes ten don itis. Th e path ology is in f am m ation o th e bu rsa, located betw een th e Ach illes ten don an d calcan eu s. Th is is a resu lt o repetitive m icrotrau m a to th e h eel area brou gh t abou t by in adequ ate cu sh ion in g du rin g h eel strike. Proper oot w ear, tech n iqu e, an d terrain are im portan t actors th at n eed to be con sidered in order to preven t th is in ju ry [3] ( ig 3 5 ).

C ro n ic co m p a r t m e n t s n d ro m e 3

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Th e sym ptom s u su ally su bside as th e activity is discon tin u ed. Th is syn drom e m u st be di eren tiated rom in term itten t clau dication [3, 13, 14].

b

ig 3 4 a upture d Achille s te ndon a Pre ssure on the gastrocne m ius m uscle s transfe rs m ove m e nt to the calcane us via the Achille s te ndon If the te ndon is rupture d, no m ove m e nt of the hindfoot occurs

ig 3 5

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6

In atigu e or stress ractu res, correct diagn ostics are essen tial. O ten th e in itial x-rays w ill sh ow n o ractu re. How ever, ocal periosteal th icken in g m ay be th e rst clu e. An MRI can o ten con rm th e diagn osis lon g be ore an x-ray can [15].

Th ese ractu res are especially dan gerou s as th ey can resu lt in a delayed u n ion or even n on u n ion . Th e rst ch oice o treatm en t is rest or im m obilization , pre erably in a cast. In cases o n on h ealin g, u rth er treatm en t su ch as au tologou s bon e gra tin g or drillin g o th e ractu re m ay be in dicated [3, 14].

A ran ge o im m ediate an d lon ger term treatm en ts can be con sidered ollow in g an overload in ju ry. Th ese in clu de: • Non operative treatm en t, by applyin g th e basic prin ciples o rest an d coolin g (ice) as w ell as com pression an d elevation o th e lim b in order to con trol edem a, pain , an d h em orrh age • Adm in isterin g an tiin f am m atory dru gs w h en n ecessary • Iden ti yin g an y risk actors or precipitatin g even ts cau sin g th e in ju ry • Bracin g an d castin g w h en applicable or protection an d im m obilization in order to restrict a certain type o m ovem en t • Im plem en tin g a w ell-plan n ed ph ysical th erapy/ reh abilitation program cen tered on a progressive u n ction al exercise regim en s w ith th e objective o retu rn in g to th e prein ju ry level o activity • How ever, su rgical m an agem en t is in dicated in cases o ailed con servative treatm en t in addressin g issu es o persisten t pain , in stability, or n erve com pression .

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Th e patien t w ill experien ce sh in pain u n der repetitive or excessive loadin g o th e posterom edial low er th ird o th e tibia. With rem oval o th e load, w ith or w ith ou t a cast, th e ten dern ess w ill disappear w ith in 4–8 w eeks [15].

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Th ese are o ten localized at th e u pper posterior m argin o th e calcan eu s. Th e x-ray w ill sh ow typical den sity or sclerosis in lateral view , bu t MRI diagn ostics are m ore sen sitive. Th e appropriate treatm en t is load bearin g restriction an d, pre erably, im m obilization in a cast [1]. 5 4

provides an overview o th e variou s types o overload in ju ries an d th e ch apters coverin g th e appropriate n on operative treatm en t option s.

St re s s fra ct u re s o f t e m e t a t a rs a ls

Th is in ju ry is also kn ow n as a “m arch ractu re” as it is gen erally seen in arm y recru its h avin g to m arch or lon g periods o tim e. It u su ally in volves th e secon d, th ird, an d ou rth m etatarsals as th ey absorb th e greatest stress du rin g pu sh o . In th e x-ray, partial or com plete bon e ractu res can be docu m en ted. Risk actors associated w ith th is in ju ry typically are periods o tran sition w h ere th ere is an in creased requ en cy an d du ration o activity w ith lim ited in tervals o rest. Oth er con tribu tin g actors are com orbid con dition s, su ch as rh eu m atoid arth ritis, an d diabetic oot n eu ropath y [3, 15] ( ig 3 6 ).

ig 3 6 Stre ss fracture s can occur in m e tatarsals II I as the se absorb the gre ate st stre ss during push off arrow

5

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Author Mile s rancis T Dela osa

16.3 Cylinder long leg cast using synthetic combicast techni ue

sgood Schlatter disease

16.3 Cylinder long leg cast using synthetic combicast techni ue

Stress fracture of the anterior tibial cortex

uptured Achilles tendon

16.10 Dorsal short leg splint using plaster of Paris 16.11 Dorsal short leg splint using synthetic 16.12 Short leg cast using rigid synthetic 16.13 Short leg cast using synthetic combicast techni ue

16.10 Dorsal short leg splint using plaster of Paris 16.11 Dorsal short leg splint using synthetic 16.12 Short leg cast using rigid synthetic 16.13 Short leg cast using synthetic combicast techni ue

Stress fracture of the calcaneus

16.11 Dorsal short leg splint using synthetic 16.12 Short leg cast using rigid synthetic 16.13 Short leg cast using synthetic combicast techni ue 16.14 Antirotation short leg cast using synthetic combicast techni ue 16.18 Foot cast using synthetic combicast techni ue 16.19 emovable foot cast using synthetic combicast techni ue

etatarsal stress fractures

16.16 Fifth metatarsal cast using synthetic combicast techni ue 16.17 emovable fifth metatarsal cast using synthetic combicast techni ue 16.18 Foot cast using synthetic combicast techni ue 16.19 emovable foot cast using synthetic combicast techni ue

etrocalcaneal bursitis Dance injuries

16.10 Dorsal short leg splint using plaster of Paris 16.11 Dorsal short leg splint using synthetic 16.12 Short leg cast using rigid synthetic 16.13 Short leg cast using synthetic combicast techni ue 16.15 emovable ankle splint using synthetic combicast techni ue 16.16 Fifth metatarsal cast using synthetic combicast techni ue 16.17 emovable fifth metatarsal cast using synthetic combicast techni ue 16.18 Foot cast using synthetic combicast techni ue 16.19 emovable foot cast using synthetic combicast techni ue

Chronic (exertional) compartment syndrome

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Ove rvie w of the various t pe s of ove rload in urie s and the chapte rs cove ring appropriate tre atm e nt

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Su m m a r

• Com m on overload related so t-tissu e in ju ries in clu de little-leagu e elbow syn drom e, qu adriceps ten don itis, ru ptu red Ach illes ten don , dan ce in ju ries, an d stress ractu res • Wh ile n on operative treatm en t can be u sed to treat m ost orm s o overload in ju ry, th e m ost im portan t step in in ju ry preven tion is to h ave previou sly establish ed th e in dividu al’s lim its o per orm an ce.

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• Overload in ju ries occu r du e to excessive orce loads, an d are in f u en ced by in trin sic actors (age, f exibility, stren gth , previou s in ju ries) an d extrin sic actors (th e dem an ds o th e speci c sport/ w ork activity) • Wh ile bon es an d so t-tissu e can adapt to th e variou s orces, repetition o th e activity can lead to a ailu re in adaptation , resu ltin g in tissu e breakdow n an d overu se in ju ry

e fe re n ce s 1.

ild e r

u r t e r re a d in g

P, Se t i S . Overu se in ju ries:

ten din opath ies, stress ractu res, com partm en t syn drom e, an d sh in splin ts. Clin Sports Med. 20 04 Jan ; 23(1):55 –81. 2.

a n e rs , a n ie t e rge n B, It o , e t a l . Simu lation o trabecu lar rem odelin g

an d atigu e: is rem odelin g h elp u l or h arm u l? Bone. 2011 May; 4 8(5):1210 –1215. 3.

4.

5.

6.

7.

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o u ie r P,

it e T,

il la n T, e t a l . The

Sports Medicine Patient Advisor. 3rd ed. Am h erst, USA: SportsMed Press; 2010:3, 4 4, 79, 202, 326. est , u . So t-tissu e ph ysiology an d repair. Vaccaro AR (ed). A AOS Orthopaedic Knowledge Update 8. 1st ed. Rosem on t, USA: Am erican Academ y o Orth opaed ic Su rgeon s; 2005:15 –27. u ca . Med ical care o ath letes. A AOS Orthopaedic Knowledge Update 8. 1st ed. Rosem on t, USA: Am erican Academ y o Orth opaedic Su rgeon s; 2005:149 –158. Be rn s t e in , Pe p e , a p la n . Sh ou lder an d elbow d isorders in th e ath lete. Flyn n J (ed). A AOS Orthopaedic Knowledge Update 10. 1st ed. Rosem on t, USA: Am erican Academ y o Orth opaedic Su rgeon s; 2011:315 –324. Ca s s a s , Ca s s e t t a ri a s . Ch ild h ood an d adolescen t sport-related overu se In ju ries. American Family Physician. 2006 Mar 15; 73(6):1014 –1022.

8.

i ,

e ffe rn a n

,

o r t im e r S . Upper

extrem ity stress ractu res an d spon dylosis in an adolescen t baseball pitch er w ith an associated en docrin e abn orm ality: a case report. Journal Pediatric Orthopedics. 2010 Ju n ; 30(4):339 –43. 9. Sa fra n , m a d CS, la t ra c e NS . Uln ar collateral ligam en t o th e elbow. Arthroscopy. 20 05 Nov; 21(11):1381– 1385. 10. Sn id e r , re e n , o n s o n T, e t a l Essen tials o m u scu loskeletal care. A AOS Orthopaedic Knowledge Update 9. 1st ed. Rosem on t, USA: Am erican Academ y o Orth opaed ic Su rgeon s; 2010:4 6, 136, 356, 387. 11. Ca m p o , Co e l o , Ba s t o s N, e t a l . In vestigation o risk actors an d ch aracteristics o dan ce in ju ries. Clin J Sport Med. 2011 Nov; 21(6):493 –498. 12. a n , Bro n , a S, e t a l . Overu se in ju ries in classical ballet. Sports Med. 1995 May; 19(5):341–357. 13. C a ra , a t o li , Pa vlo vic r. Sports m ed icin e. M iller M D (ed). Review of Orthopaedics. 4th ed. Ph iladelph ia: Sau n ders Elsevier; 200 4:228 –230. 14. a rt , Ba u m e ld , ille r . Sports m ed icin e. M iller M D (ed). Review of Orthopaedics. 5th ed. Ph iladelph ia: Sau n ders Elsevier; 2008:263 –26 4. 15. Pa t e l S, o t , a p il N . Stress ractu res: d iagn osis, treatm en t, an d preven tion . American Family Physician. 2011 Jan 1; 83(1):39 –46.

Cra ig

I Cu rren t developm en ts con cern in g

m ed ial tibial stress syn drom e. Phys Sportsmed. 2009 Dec; (4):39 –40. o e rig , Ba u m a u e r , io rd a n o B , e t a l Disorders o th e oot an d an k le. M iller

M D (ed). Review of Orthopaedics. 5th ed. Ph iladelph ia: Sau n ders Elsevier; 2008:359 – 402. S ea

,

a n le T In ju ries an d con d ition s o

th e ped iatric an d adolescen t ath lete. A AOS Orthopaedic Knowledge Update 10. 1st ed. Rosem on t, USA: Am erican Academ y o Orth opaedic Su rgeon s; 2011:783 –793. St o r

C m e t TC Sh in splin ts: pain u l to

h ave an d to treat. Compr Ther. 2006 Fall; 32(3):192 –195.

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

TEC NI

ES

Casts, splints, and support bandages— techni ues

Techni ues

4

ve r vie o f ca s t , s p lin t , o r t o s is , a n d la u s re s in g , o s n ge le n

4

ve r vie o f ca s t , s p lin t , o r t o s is , a n d d e m o n s t ra t io n fo rm a t a n d ico n s la u s re s in g , o s n ge le n

5 6

p p e r e t re m it la u s re s in g , o s o e r e t re m it la u s re s in g , o s Sp in e la u s

5

a n d a ge t e c n i u e s —

3 5 n ge le n 46 n ge le n 5 5

re s in g , o s

Su p p o r t a n d a ge s la u s re s in g , o s

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n ge le n 6 5 n ge le n

Klaus Dre sing, os Engele n

4

Overview of cast, splint, orthosis, and bandage techni ues 5

Se u e n ce o f e a m in a t io n a n d t re a t m e n t Exam ination racture re duction Cast proce dure Docum e ntation

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Ca s t ro o m p re p a ra t io n

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T p e s o f im m o ili a t io n Prim ar fracture care Prim ar de finitive fracture care

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T p e s o f m a t e ria ls Tube bandage stoc ine tte Cast padding and the prote ction of bon prom ine nce s Cast m ate rial

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Pa in re lie f Ane sthe tics Analge sia

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Authors

e d u cin g t e fra ct u re X ra re vie w during re duction Pa t ie n t p o s it io n in g oint position Shoulde r position Elbow position Position of proxim al and distal radioulnar oints rist position Position of finge rs and hand ip position Kne e position An le position oot oints D nam ic splinting afte r Kle ine rt

6

5

Overvie w of cast, splint, orthosis, and bandage te chni ue s

p p l in g a n d a n d lin g ca s t m a t e ria l Appl ing plaste r of Paris Appl ing s nthe tic Num be r of cast m ate rial la e rs Trim m ing and m olding of cast e dge s or ing and se tting tim e Cast fe ne stration windowing Ba n d a gin g t e c n i u e s alf ove rlapping te chni ue Criss cross te chni ue Stre tch re lax te chni ue igure of e ight te chni ue Ca s t s p lit t in g t e c n i u e s a n d ca s t re m o va l Oscillating cast saw e fixing the cast Pa t ie n t in fo rm a t io n 3

e vie

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u ra t io n o f im m o ili a t io n

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5

and a ssessment

Su m m a r

4 4 5 5

Authors

Klaus Dre sing, os Engele n

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Overview of cast, splint, orthosis, and bandage techni ues

In th is th ird an d n al section , th e tech n iqu es or preparin g an d applyin g casts, splin ts, orth oses, an d su pport ban dages are presen ted. It ou tlin es th e in dividu al steps or 55 castin g an d im m obilization procedu res, coverin g th e u pper extrem ity, th e low er extrem ity, an d th e spin e. Bu t ju st as w ith an y in vasive procedu re, preparation an d plan n in g is m an datory be ore begin n in g to apply a n on in vasive im m obilization ban dage. It is th ere ore recom m en ded th at prior to th e procedu re th e caregiver obtain s th e relevan t m aterials an d h as a u ll u n derstan din g o th e ollow in g: • Th e sequ en ce or exam in ation an d treatm en t • Resou rces an d sta n g n eeds • Th e variou s types o im m obilization • Th e variou s types o m aterials • Pain relie • Fractu re redu ction • Patien t an d lim b position in g • Applyin g an d h an dlin g cast m aterials • Ban dagin g tech n iqu es • Cast splittin g an d cast rem oval • Patien t in orm ation an d con sen t • Con trols an d review s • Du ration o im m obilization .

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Th e process o applyin g a cast, splin t, or orth osis is in itiated by th e ph ysician ’s decision th at som e orm o im m obilization is in dicated, as a part o n on operative or perioperative care. I im m obilization is n ecessary, th e requ ired resou rces m u st be prepared. Th ese m ay in clu de assistan ce an d appropriate acility, bu t appropriate su pplies an d equ ipm en t are alw ays requ ired. Sin ce th e variou s cast m aterials h ave di eren t properties, th e pro ession al u ser m u st select th e m aterial th at w ill best t th e type o ractu re or lesion , th e body region , or th e age o th e patien t. Th e m edical in dication s or im m obilization h ave been spelled ou t in section 2 Gu idelin es.

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In t ro d u ct io n

Skill u l application o th e cast by th e trau m a or orth opedic residen t or su rgeon is essen tial or good resu lts [1]. Th e ph ysician con rm in g th at im m obilization is in dicated sh ou ld o cou rse also be able to person ally apply th e cast, splin t, orth osis, or su pport ban dage th em selves. On ly th is experien ce an d u n derstan din g w ill en able th e su rgeon to assess casts applied by residen ts, cast tech n ician s, or oth er caregivers. An d on ly w ith th is kn ow ledge an d experien ce w ill h e/ sh e be able to obtain th e com preh en sive in orm ed con sen t an d provide an in orm ed disch arge or th e patien t (see ch apter 3 Prin ciples o castin g).

Th is ch apter th ere ore provides th e reader w ith an essen tial overview an d tech n iqu e tips or th e e ective an d sa e application o im m obilization ban dages.

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Overvie w of cast, splint, orthosis, and bandage te chni ue s

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Se u e n ce o f e a m in a t io n a n d t re a t m e n t

In th e case o n on operative ractu re care, th e sequ en ce o exam in ation an d treatm en t is as ollow s: • Exam in ation an d diagn osis • Fractu re redu ction • Application o castin g m aterials • Assessm en t o redu ction an d im m obilization • Docu m en tation . a m in a t io n

In th e previou s section Gu idelin es, th e process or exam in ation an d diagn osis is ou tlin ed or each o th e extrem ities. Typically, th e rst step in an y treatm en t is th e m edical h istory, in clu din g m ech an ism o in ju ry, ollow ed by a com plete m edical exam in ation an d relevan t diagn ostic tools. Wh en exam in in g th e in ju red extrem ity an d body region , look or th e ollow in g sign s: • Localized ten dern ess, sw ellin g, de orm ity, or in stability • Un w illin gn ess or in ability to m ove or u se th e part n orm ally • Visible bon e in ju ry in an open w ou n d • Abn orm al m obility at su spected ractu re site • Bon y crepitu s • Fractu re eviden t by x-ray. Th is is ollow ed by exam in ation o th e ractu re region an d distal extrem ity or: • Trau m atic skin lesion • Hem atom a • So t-tissu e in ju ry • Vascu lar in ju ry • Nerve lesion .

ra ct u re re d u ct io n

Th e sequ en ce o ractu re redu ction is n early th e sam e in all extrem ities, an d sh ou ld ollow th is sequ en ce: • E ective elim in ation o pain , w ith an algesia or an esth esia – Local – Region al – Gen eral • Traction (exten sion ) in lon gitu din al axial direction • “Hookin g-togeth er” o th e ragm en ts, w h en th e ractu re pattern perm its • Align m en t alon g th e an atom ical axis (rotation an d an gu lation ). 3

Ca s t p ro ce d u re

Th e order an d steps or applyin g th e cast or splin t are as ollow s: • Lin in g layer over th e skin , u sin g tu be ban dage (stockin ette) • Paddin g • Application o plaster o Paris or syn th etic cast m aterial • Moldin g • Splittin g o th e cast (in prim ary ractu re care th is is m an datory) • An ch orin g, w ith gau ze or elastic ban dage. Take care to protect th e patien t’s cloth in g again st con tact w ith plaster or syn th etic cast m aterial. 4

o cu m e n t a t io n

Th ese vital steps sh ou ld be ollow ed (see th e topics Pretreatm en t m edical in orm ation an d in orm ed con sen t, an d Posttreatm en t patien t in orm ation an d cast ch eck in ch apter 3 Prin ciples o castin g): • All resu lts o th e m edical exam in ation sh ou ld be docu m en ted in w ritin g • All redu ced ractu res w ill be docu m en ted w ith x-ray review • I a patien t is u n able to sign or give in orm ed con sen t du e to h is/ h er in ju ry, th e in orm ation is docu m en ted by th e ph ysician . Docu m en tation o th e n eu rovascu lar statu s an d x-ray review at th e en d o th e cast/ splin t procedu re is m an datory be ore th e patien t is allow ed to leave th e em ergen cy departm en t.

Each o th e elem en ts in th e sequ en ce or castin g is u rth er detailed in th is ch apter.

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Prior to an im m obilization procedu re, en su re th at all n ecessary m aterials, in stru m en ts, an d equ ipm en t are readily available. Ch eck m on itorin g equ ipm en t, en ergy, ligh tin g, an d w ater su pply, an d prepare im age view in g equ ipm en t, i n eeded. Prepare th e cast cart (trolley) an d m ove it in to place w ith in easy reach . Sim ilarly, prepare th e cast table, cu sh ion s to su pport extrem ities, an d oth er u rn itu re so th at th e patien t can be position ed appropriately be ore begin n in g th e procedu re. Rem em ber th at th e m aterials h ave a lim ited w orkin g an d settin g tim e, so it is im portan t n ot to in terru pt th e procedu re. Th e cast room m u st h ave an appropriate plaster sin k an d trap. Wh en u sin g plaster o Paris, plaster is lost in to th e w ater. With ou t separatin g th is plaster rom th e w astew ater, th e ou tlet pipes w ill soon clog w ith h arden in g plaster slu dge. A bu cket or plaster basin can be u sed or dippin g an d w ettin g plaster closer to th e patien t, bu t th ese sh ou ld alw ays be em ptied in to an appropriately drain ed plaster sin k. Appropriate w aste disposal con tain ers sh ou ld be readily available or both con tam in ated an d n on m edical w aste. Norm ally a cast tech n ician is th e person applyin g th e casts bu t operatin g room person n el or n u rsin g sta m ay also be train ed to apply casts an d ban dages. Every trau m a or orth opedic su rgeon sh ou ld also be train ed an d able to apply casts an d ban dages. Fractu re redu ction , h ow ever, is alw ays th e task o th e su rgeon .

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T p e s o f im m o ili a t io n

Wh en con siderin g w h at type o im m obilization is requ ired, th e ph ysician m u st assess th e stage an d severity o th e in ju ry, th e poten tial or in stability, th e risk o com plication s, an d th e patien t’s u n ction al requ irem en ts (see also ch apter 3 Prin ciples o castin g) [2]. A cast is applied in a circu m eren tial m an n er arou n d th e extrem ity. Split casts are o ten u sed in prim ary ractu re care a ter redu ction o com plex ractu res, bu t n on split casts are rarely in dicated in de n itive ractu re care. A cast is th e rst ch oice in cases in volvin g n on com plian t patien ts becau se casts are m ore di cu lt or patien ts to rem ove by th em selves. In special in dication s, prim ary de n itive ractu re care w ith sem irigid syn th etic cast m aterials cou ld be con sidered. Boyd et al su m m arized th at “casts provide m ore e ective im m obilization , bu t requ ire m ore skill an d tim e to apply an d h ave a h igh er risk o com plication s i n ot applied properly” [2].

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For th e application o plaster o Paris (POP) an d syn th etic im m obilization ban dages, th e specially equ ipped room called a cast room is recom m en ded ( ig 4 ) (see ch apter 5 Logistics an d resou rces in th e cast room ). Wh ile oth er n on operative an d ban dagin g activities can also take place in th is room , it is specially design ed or e cien t cast application , in clu din g sa ety m easu res or patien t an d sta .

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Ca s t ro o m p re p a ra t io n

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A splin t does n ot circu m eren tially su rrou n d th e extrem ity an d th ere ore allow s so t-tissu e expan sion du rin g th e posttrau m atic in f am m atory ph ase. Splin ts are o ten u sed in in itial ractu re care, as w ell as or sprain s, ten don in ju ries, so t-tissu e in ju ries, n erve in ju ries, an d postoperatively. Splin ts m ake it easier to exam in e or redress th e w ou n d, becau se th ey are easier to rem ove th an a u lly circu lar (closed) or split plaster cast. Orth oses, rem ovable casts, an d su pport ban dages allow m u ch easier access to th e lim b, bu t provide less stability. Th eir u se is particu larly in dicated w h en u n ction al th erapy is con sidered appropriate.

Cast room with e uipm e nt

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Overvie w of cast, splint, orthosis, and bandage te chni ue s

Prim a r fra ct u re ca re

5

Th e in itial (prim ary) treatm en t o a ractu red bon e is redu ction (i n ecessary), reten tion , an d im m obilization o th e extrem ity. In prim ary ractu re care, a splin t is o ten u sed a ter redu ction o th e ractu re becau se o th e likelih ood o so t-tissu e sw ellin g. An oth er im m obilization m eth od is th e application o a POP cast th at is m an datorily split to allow w iden in g o th e cast, again in expectation o so t-tissu e sw ellin g. Norm ally, th is in itial split cast or splin t is th en replaced by a n al de n itive cast a ter 2-3 w eeks.

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Note th at you sh ou ld alw ays read th e in stru ction s o u se rom th e cast an d paddin g m aterial care u lly be ore w orkin g w ith th e m aterial.

Prim a r d e fin it ive fra ct u re ca re

In special in dication s, a cast is applied on ly on ce at adm ission in h ospital, an d n o replacem en t is n eeded (h en ce it is called th e de n itive cast). For th ese in dication s, su ch as n on displaced ractu res, or pediatric green stick ractu res, th e patien t is treated w ith a split syn th etic cast (eg, sem irigid or u sin g th e com bicast tech n iqu e). A ter th e sw ellin g h as decreased (n orm ally a ter on e w eek) th e split cast is u rth er redu ced in diam eter by cu ttin g aw ay a strip o cast m aterial. Th e cast is th en closed u sin g an oth er roll o sem irigid cast m aterial or by xin g it w ith an elastic ban dage or velcro strips. Th is process also perm its tigh ten in g o a cast th at h as becom e loose on ce sw ellin g resolves.

T p e s o f m a t e ria ls

As ou tlin ed in ch apter 6 Properties o cast m aterials, casts, splin ts, an d orth oses all ollow th e sam e m odu lar con stru ction : • Lin in g m aterial ie, tu be ban dage (stockin ette) • Paddin g • Castin g m aterial.

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Tu e

a n d a ge s t o c in e t t e

Adapt th e tu be ban dage diam eter to th e extrem ity or body region ( Ta le 4 . Do n ot tigh ten or stretch th e tu bu lar ban dage too m u ch as th is can lead to h igh skin pressu re an d can resu lt in com partm en t syn drom e i n ot cu t open at th e en d o th e application . On ce th e rst layer is applied, keep th e join t an d lim b in th e desired position . Avoid w rin kles, as th ey can lead to pressu re sores ben eath th e cast or splin t. Site of cast

Diameter of tube bandage1

Finger

Approximately 2–2.5 cm

Upper extremity

Approximately 5–7.5 cm

Lower extremity

Approximately 7.5–10 cm

De pe nding on the brand of the tube bandage Ta le 4 e com m e nde d diam e te r of tube bandage in re lation to bod re gion

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Site of cast

Recommended padding width

Hand

Approximately 5 cm

Upper extremity

Approximately 5–7.5 cm

Foot

Approximately 5 cm

Lower extremity

Approximately 10–15 cm

Ta le 4 e com m e nde d width for cast padding rolls in re lation to bod re gion

Th e paddin g sh ou ld u su ally exten d beyon d th e in ten ded edge o th e cast or splin t by 1–2 n gers breadth . Cast paddin g is n orm ally applied u sin g th e “h al -overlappin g tech n iqu e” (see topic 10 Ban dagin g tech n iqu es in th is ch apter). Paddin g is n orm ally on ly applied a ter th e desired join t position , u su ally th e n eu tral (or “ u n ction al”) position , h as been ach ieved (see topic 8 Patien t position in g in th is ch apter). Do n ot apply paddin g arou n d join ts, or exam ple, th e elbow join t, be ore th e n al position is reach ed. I th is is n ot don e care u lly, poorly tted paddin g can com press th e con cave region , an d cau se pressu re th at m igh t cau se sw ellin g rom ven ou s com pression , skin in ju ry, n erve palsy, or isch em ia.

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Cast paddin g acts as a protection layer betw een th e cast m aterial, skin , an d so t tissu e (see also ch apter 6 Properties o cast m aterials). Th e recom m en ded w idth o rolled cast paddin g in relation to th e body region is ou tlin ed in Ta le 4 .

A layer o w ater-resistan t crepe paper ban dage can be u sed over th e paddin g be ore w et plaster or syn th etic cast m aterials are applied. Th is can be u sed to “sn u g-u p” an d secu re th e paddin g or sm ooth , gen tle com pression . Un derw rap is n ecessary to allow an even com pression o th e paddin g layers an d to separate th e dry paddin g rom th e w et POP. Th is layer also keeps w ater an d dissolved plaster rom w ettin g th e paddin g layers, resu ltin g in h arden in g o th e paddin g an d th e poten tial or pressu re sores. At tim es, extra paddin g, typically as a ocal patch in stead o circu m eren tially, h as to be applied at th e “bon y prom in en ces” an d vessels. A bon y prom in en ce is a part o a bon e th at sticks ou t or protru des, su ch as a kn obby kn ee or sh ou lder blade, an d th ey are o ten n ot w ell covered by so t tissu e or are position ed im m ediately u n der th e skin su r ace. Bon y prom in en ces are areas w ith a h igh risk o developin g pressu re sores or oth er dam age. Addition ally, n erves ru n n in g directly alon g th e bon e n ear th e prom in en ces are also in dan ger o su erin g in ju ry, su ch as n erve palsy.

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In th e u pper lim b, th e prom in en ces in clu de th e in n er epicon dyle o th e h u m eru s, th e tip o th e elbow , an d th e styloid process at th e w rist. In th e low er lim b, areas requ irin g extra protection in clu de th e h eel, m alleoli, th e patella, th e h ead o th e bu la, an d th e greater troch an ter. Prom in en ces o th e torso in clu de th e sacru m / coccyx, th e an terior su perior iliac spin es or iliac crest, an d th e isch ial tu berosity o th e spin al process. Particu larly w ith syn th etic casts, addition al pieces o oam or elt paddin g to cover th ese sen sitive places are recom m en ded. ig 4 3 in dicates th e m ost sen sitive location s, an d th ese are u rth er h igh ligh ted in each o th e castin g tech n iqu e dem on stration s in ch apters 15 to 18.

I n gers or toes are in clu ded in a cast or splin t, th e in terdigital space sh ou ld be protected again st m aceration w ith addition al tu be ban dages or paddin g ( ig 4 ). More paddin g layers can also be u sed i so t-tissu e sw ellin g, to a large exten t, is to be expected.

ig 4 Extra prote ction of the inte rdigital space be twe e n the nge rs or toe s is som e tim e s re uire d

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Clavicle

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Acrom ion

Oute r cond le of hum e rus Inne r m e dial ulnar cond le of hum e rus and ulnar ne rve Ante rior supe rior iliac spine s

re ate r trochante r

S m ph sis

Pate lla

e ad of bula and pe rone al ne rve

Tibial cre st

Inne r m alle olus

Oute r malle olus

PIP of st toe

ig 4

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on prom ine nce s, ne rve s, and ve sse ls ne e ding e xtra padding

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

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Klaus Dre sing, os Engele n

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Scapula

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Tip of e lbow ole ocranon Iliac cre st Ische al tube rosit Sacrum cocc x

adial st loid proce ss lnar st loid proce ss

ate ral fe m oral cond le Me dial fe m oral cond le

Achille s te ndon tube r calcane i th m e tatarsal he ad

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Ca s t m a t e ria l Pla s t e r o f Pa ris

5 3

Th e m ain advan tage o plaster o Paris is its pliability an d m oldability (see also ch apter 6 Properties o cast m aterials). Ta le 4 3 provides a list o th e appropriate dim en sion s or POP cast m aterial in relation to th e respective area o application .

S n t e t ic

Th e advan tages o syn th etic cast m aterial are its stability, w ater resistan ce, low w eigh t, an d sh orter settin g an d h arden in g tim e (see also ch apter 6 Properties o cast m aterials) in com parison to POP. Ta le 4 4 provides a list o th e appropriate dim en sion s or syn th etic cast m aterial in relation to th e respective area o application .

Site of cast

Recommended width of plaster of Paris cast rolls

Site of cast

Recommended width of synthetic cast rolls

Hand

6–8 cm

Hand

2.5–5 cm

Upper extremity

8–10 cm

Upper extremity

5–7.5 cm

Foot

6–8 cm

Foot

5–7.5 cm

Lower extremity

10–15 cm

Lower extremity

7.5–10 cm

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Ta le 4 3 idth re com m e ndations for plaste r of Paris cast m ate rial in re lation to bod re gion

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Ta le 4 4 idth re com m e ndations for s nthe tic cast m ate rial in re lation to bod re gion

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Wh ile an an esth etic m ay n ot be requ ired, a stron g an algesic can still m ake th e procedu re m ore tolerable, an d im proves th e patien t’s ability to relax an d cooperate. Con sider an algesia alon e i th e ractu re is stable, w h en m an ipu lation is n ot n ecessary, or i a recen t in ju ry’s pain h as sign i can tly resolved. Use som e orm o an esth esia or m ore severe pain , an d i relaxation is n ecessary or th e redu ction . In an y case, it is essen tial to assess th e patien t’s n eed or pain relie an d provide it adequ ately. Th is m ay requ ire a ch an ge in plan s i discom ort proves m ore th an an ticipated. Wh ile a given procedu re m ay be satis actorily tolerated by an adu lt w ith an algesia plu s local or region al an esth esia, a ch ild is u su ally m ore com ortable w ith a gen eral an esth etic. It is essen tial or th e su rgeon to be aw are o th e available m edication s an d th eir ph arm acologic aspects, as w ell as h is/ h er in stitu tion ’s pain m an agem en t policies an d th e n ecessary sa ety precau tion s. Patien t allergies m u st be iden ti ed. Aw aren ess o m axim al allow able doses o an y local an esth etic is im portan t. Particu larly i given rapidly, th e possibility o cau sin g a seizu re m u st be con sidered w h en u sin g a so-called h em atom a block (see below ), sin ce an in jection in to a bon e’s in tram edu llary space is essen tially an in traven ou s in jection . An tidotes or reversal o n arcotics an d ben zodiazepin es sh ou ld be available. Wh en ever in traven ou s sedation is u sed, an em ergen cy cart is requ ired. Th is m u st con tain devices or su ction , positive pressu re breath in g, an d airw ay establish m en t. All m em bers o th e treatm en t team m u st be aw are o h ow to requ est an em ergen cy resu scitation team (“code call”).

n e s t e t ics 4

An esth etics are classi ed accordin g to rou te o adm in istration as: • Local an esth esia, in jected in to th e in volved area • Region al an esth esia – Neu raxial: spin al or epidu ral, or – Periph eral: via plexu s or sin gle n erve blocks – An oth er orm o region al an esth esia, available in som e in stitu tion s, is an in traven ou s region al or Bier block, u sed w ith an arterial tou rn iqu et • Gen eral an esth esia, w ith in h alation an d or in traven ou s m edication s.

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Acu te ractu res are n orm ally qu ite pain u l. For ractu re redu ction , an d som etim es even or cast application w ith ou t ractu re m an ipu lation , som e orm o an algesia an d/ or an esth esia is n eeded. Fractu re redu ction , or even ju st splin t application , are procedu res th at can tem porarily in crease pain . For patien t com ort, an d m u scle relaxation to acilitate ractu re m an ipu lation , an an esth etic is recom m en ded typically in addition to an algesic m edication s.

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Klaus Dre sing, os Engele n

In m an y h ospitals, su rgeon s w ill adm in ister local an d som etim es region al an esth etics, w h ile an esth esiologists or n u rse an esth etists m an age m ore com plex region al as w ell as gen eral an esth etics. In som e situ ation s, oth er tech n iqu es o an esth esia/ an algesia are u sed du rin g ractu re treatm en t, su ch as a m ixtu re o n itrou s oxide an d oxygen w h ich is adm in istered to th e patien t w ith a sel -con trolled in h alation device. So-called “con sciou s sedation ” is an oth er tech n iqu e u sed du rin g procedu res, an d is o ten applicable or n on operative ractu re care. Th is in volves in traven ou s adm in istration o sedative an d an algesic dru gs, at a level th at depresses con sciou sn ess bu t allow s th e patien t to m ain tain th eir airw ay, in depen den tly an d con tin u ou sly. It requ ires a train ed n u rse or ph ysician , an d com preh en sive con tin u ou s m on itorin g by an assign ed m em ber o th e treatin g team w ith n o oth er respon sibilities. Th ere sh ou ld be a pu lse oxim eter, electrocardiograph ic m on itor, an d acilities or m easu rin g an d recordin g blood pressu re, pu lse, an d level o con sciou sn ess, as w ell as a com plete em ergen cy cart w ith all n ecessary resu scitation equ ipm en t an d su pplies. Yet an oth er tech n iqu e in volves th e u se o ketam in e, a dissociative an esth etic w ith less respiratory an d cardiac depression , bu t requ en t dysph oric e ects in adu lts. Its m ajor u se is or ch ildren .

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o ca l a n e s t e s ia

Th e h em atom a block is o ten a good altern ative to m ore com plex an esth esia, i th e ractu re is resh an d th e h em atom a is still liqu id. Prem edication w ith system ic an algesics is h elp u l. Sterile tech n iqu e is requ ired. Th e ractu re is localized by palpation or with x-ray u n der th e C-arm . A ter su bcu tan eou s application o a sm all deposit o local an esth etic, ollow ed by an appropriate reaction tim e, th e n eedle is in serted in to th e gap betw een th e m ain ragm en ts ( ig 4 4 ). A ter bon e con tact w ith th e n eedle, aspiration o blood con rm s th at th e n eedle is correctly located w ith in th e h em atom a ( ig 4 5 ). Th e aspiration o at droplets is addition al eviden ce o correct position in g o th e n eedle ( ig 4 6 ). In ject 5–10 m l o an esth etic ( or exam ple, 0.5% or 1% lidocain e w ith ou t epin eph rin e) stepw ise a ter aspiration o as m u ch h em atom a as possible. Th is m ay be easier w ith a larger bore n eedle, a ter th e in itial in jection w ith a sm aller on e. Hem atom a rem oval m ay decrease th e pressu re in th e ractu re gap.

ig 4 4 A ne e dle with local ane sthe tic is inse rte d into the gap be twe e n the m ain fracture fragm e nts

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Du rin g th e creation o a h em atom a block, th e patien t can becom e an xiou s, in w h ich case m u scle spasm s are com m on . Su cien t tim e sh ou ld be allow ed or th e patien t to adapt to th e situ ation an d or th e dru g to act. Th e su rgeon sh ou ld in orm th e patien t o all steps o treatm en t; h e or sh e sh ou ld calm th e patien t an d create a pro ession al atm osph ere or treatm en t. With pain relie , th e m u scles w ill be m ore relaxed an d ractu re redu ction can be per orm ed m ore easily an d e ectively.

ig 4 5 Afte r subcutane ous in e ction of a small de posit of local ane sthe sia, the ne e dle is guide d into the fracture he matom a The aspiration of blood into the s ringe is proof of corre ct positioning of the ne e dle into the fracture gap

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

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Th ere are a n u m ber o n erve blocks com m on ly u sed in clin ical practice: • Upper extrem ity: in terscalen e block, axillary (brach ial plexu s) block, m edial, u ln ar, an d digital blocks • Low er extrem ity: em oral, sciatic, saph en ou s, su ral an d an kle blocks • Digital n erve blocks are requ en tly u sed in th e em ergen cy departm en t or n ger in ju ries an d distal in ection s ( elon s an d paron ych iae).

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Gen eral an esth etics o er advan tages or ch ildren , especially pain - ree in du ction , reliable an esth esia, good m u scle relaxation , an d am n esia or th e procedu re. Th ey sh ou ld be con sidered w h en ever ractu re redu ction is bein g plan n ed or a you n g ch ild [3]. A gen eral an esth etic is certain ly an option or an y sign i can t ractu re m an ipu lation in an adu lt as w ell. Som etim es th e com bin ation o a region al an esth etic w ith a low er level o gen eral an esth esia n icely balan ces th e ben e ts o both tech n iqu es. Collaboration w ith an an esth esiologist is o ten h elp u l in ch oosin g th e m ost appropriate m ean s o pain con trol, an d is h igh ly recom m en ded w h en patien ts h ave com plicatin g m edical issu es. Th e su rgeon sh ou ld discu ss w ith th e an esth esiologist th e plan n ed procedu re, its steps (su ch as th e n eed to assess x-rays be ore aw aken in g th e patien t), th e n eed or m u scle relaxation , an d oth er relevan t details.

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Periph eral region al an esth esia is ach ieved by in jection o an appropriate volu m e o local an esth etic adjacen t to th e n erves su pplyin g th e an atom ic region or w h ich an esth esia is desired. I a stru ctu ral sh eath en velopes th e n erves (eg, brach ial plexu s) th e in jection sh ou ld ll an d disten d th is stru ctu re. A su ccess u l region al an esth etic sh ou ld elim in ate sen sation an d m otor u n ction in th e distribu tion o th e blocked n erves, th rou gh its in h ibition o n erve m em bran e depolarization . Norm ally, seriou s com plication s rom region al an esth esia are exceedin gly rare.

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Note the man fat drople ts aspirate d from the m e dullar space

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ig 4 6 a e m atoma with fat drople ts indicate s cor re ct ne e dle place m e nt

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Overvie w of cast, splint, orthosis, and bandage te chni ue s

n a lge s ia

An algesia or ractu re m an ipu lation can be provided u sin g oral prem edication w ith a w ell-absorbed n arcotic or n on steroidal an tiin f am m atory agen t. Altern atively, a paren teral an algesic can be given , via in tram u scu lar or in traven ou s rou tes. Paren teral an algesics are o ten n eeded in itially. In traven ou s m edication s can be given w ith a patien t- con trolled device, or titrated w ith repeated sm all doses to ach ieve relie w ith ou t excessive sedation or respiratory depression . In tram u scu lar adm in istration is slow er to take e ect, an d h arder to con trol, bu t lasts lon ger.

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Typically, it is th e procedu re itsel th at is pain u l, w ith relie a ter th e cast h as been applied an d is h ard en ou gh to be an e ective splin t. Su cien t m edication to perm it a ractu re redu ction can resu lt in over-sedation a ter th e procedu re is n ish ed. Wh en ever sign i can t an algesic doses are u sed, th ey sh ou ld be appropriate or th e patien t’s age, w eigh t, an d m etabolism .

Stron g an algesics are typically n eeded or th e pain o a resh ractu re, at least or th e rst ew days a ter in ju ry [3]. Adequ ate ractu re splin tin g aids sign i can tly w ith pain con trol. Mu scle spasm s aggravate ractu re pain . Mu scle relaxan ts ( or exam ple, ben zodiazepin es) are som etim es added to an algesics, bu t th ey do n ot th em selves relieve pain , an d, in com bin ation w ith n arcotics, can produ ce excessive sedation . Sign i can t ractu re pain o ten persists or a w eek or tw o, especially w ith n on operative treatm en t. Th u s, every patien t sh ou ld receive an an algesic prescription or u se in th e postractu re an d post-redu ction periods. In addition , patien ts sh ou ld be in stru cted to con su lt th e su rgeon im m ediately i th e pain does n ot ease w ith tim e an d/ or rest, an d especially i it in creases in spite o an algesics. A com partm en t syn drom e cou ld be th e cau se o severe, in creasin g pain .

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Th e am ou n t o orce n eeded to realign th e ragm en ts depen ds on displacem en t, relaxation , an d th e location o th e ractu re, bu t especially u pon th e viscoelasticity o th e ractu re site. Su stain ed, su cien t, bu t relatively gen tle orce can gradu ally stretch th e so t tissu es su rrou n din g a resh ractu re so th at overlappin g is elim in ated, an d a gap develops betw een th e ractu re en ds (see also topic 7 Redu ction o bon e ractu res in ch apter 3 Prin ciples o castin g).

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The e ffe ct of using gravit in orde r to achie ve fracture

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Closed redu ction o a displaced ractu re, in an adu lt, typically requ ires in itial distraction , to perm it correction o th e de orm ity, an d/ or to allow h ookin g-on an d restoration o len gth stability. To distract th e ractu re site, gravity can be u sed to great advan tage ( ig 4 an d ig 4 ) (see ch apters 9.2 Fractu res, dislocation s, an d su blu xation s o th e low er extrem ity; an d 15.15 Sh ort arm cast u sin g plaster o Paris w ith traction an d redu ction ).

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Th e an atom ical realign m en t o ractu res is called redu ction . In diaph yseal ractu res, restoration o axis, bon e len gth , an d an atom ical rotation are th e goals. Wh ile th is m igh t be su cien t or m etaph yseal ractu res, displaced articu lar ractu res can n ot be an atom ically redu ced su ccess u lly w ith ou t su rgical redu ction an d xation . In m ost an atom ic region s, rotation an d an gu lar align m en t o diaph yseal ractu res can be ach ieved w ith m an ipu lation , an d o ten m ain tain ed w ith a cast. Su ccess u l m ain ten an ce o len gth can be m ore di cu lt, u n less th e en ds o tw o m ajor ractu re ragm en ts can be h ooked on to on e an oth er so th at, stabilized by extern al im m obilization , th ey do n ot redisplace an d sh orten . Fractu res th at are com m in u ted, spiral, or sign i can tly obliqu e can n ot be h ooked togeth er in a w ay th at produ ces len gth stability. I th ey are sign i can tly sh orten ed, even i tem porarily restored to appropriate len gth , th ey can be expected to retu rn to th e degree o sh orten in g eviden t on in itial u n redu ced x-rays.

Wh ile som e sh orten in g o th e h u m eru s is w ell tolerated, orearm diaph yseal ractu res m u st be xed an atom ically, an d on ly sligh t sh orten in g o th e tibia or em u r can be accepted w ith ou t com prom ise o gait.

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Klaus Dre sing, os Engele n

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ravit and fracture re duction

a The am ount of we ight to be use d in traction de pe nds on the patie nt s m uscle volum e and stre ngth

The re le vant we ight is use d to disim pact the fracture

I th e ragm en ts are im pacted (tru ly cru sh ed in to each oth er, as typically occu rs in corticocan cellou s m etaph yseal bon e), th e su rgeon w ill try to disim pact th e ractu re. Sin ce x-rays are tw o dim en sion al, it is im portan t to rem em ber th at apparen t “im paction ” m ay on ly represen t overlappin g ragm en ts. To correct tru e im paction , th e ragm en ts m u st be m obilized so th ey can be m oved in depen den tly. On e w ay to do th is is to apply orces in th e direction o th ose th at cau sed th e ractu re (“reprodu ce th e in ju ry”), an d th en correct th e ractu re de orm ity. For exam ple, w ith a typical, dorsally displaced an d an gu lated distal radiu s ractu re, on e

m ay begin by in creasin g dorsal an gu lation , in creasin g deorm ity, an d th en , w ith distractin g orce, correct th e dorsal displacem en t an d restore palm ar an gu lation . To h elp u s u n derstan d th is, Ch arn ley described th e “gear-w h eel” m ech an ism , poin tin g ou t th at disen gagem en t o th e im properly “m esh ed gears” w as n ecessary be ore de orm ity cou ld be corrected ( ig 4 ) (an d see ch apter 15.15 Sh ort arm cast u sin g plaster o Paris w ith traction an d redu ction ) [4].

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Overvie w of cast, splint, orthosis, and bandage te chni ue s

ig 4 e ar whe e l m e chanism illustration of the radius, according to Charnle m ust be corre cte d be fore re duction is possible

Note that rst im paction and the n displace m e nt

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Authors

Klaus Dre sing, os Engele n

ra re vie

d u rin g re d u ct io n

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An x-ray is m an datory to assess an d con rm a su ccess u l ractu re redu ction . Alth ou gh x-rays are poten tially dan gerou s, or both patien t an d m edical person n el, th is is th e on ly w ay to veri y th e an atom ical position o th e ractu red lim b. Norm ally, a C-arm im agin g apparatu s is u sed in th e em ergen cy departm en t or cast room . Su rgeon s an d sta sh ou ld w ear protective cloth in g du rin g x-ray exposu re: th yroid sh ield, gow n , an d, i possible, lead goggles, an d lead gloves. In creasin g th e distan ce rom an x-ray sou rce is th e best w ay o lim itin g x-ray exposu re or th e su rgeon an d sta , especially con siderin g th e in verse squ are law . Du ration o x-ray exposu re m u st also be con sidered. Man ipu lation w ith th e f u oroscope ru n n in g con tin u ou sly resu lts in greater radiation exposu re th an i brie sin gle-sh ot im ages w ere obtain ed in stead. Th ese are alm ost alw ays th e m ost appropriate ch oice o im age acqu isition [5] ( ig 4

r1

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r1 r2 ¼ dose r3 1/9 dose ig 4

The inve rse s uare law The dose is re duce d b the powe r of two of the distance to the x ra source

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Fractu re redu ction per orm ed directly over th e tu be is th e w orst position o th e C-arm w ith th e h igh est radiation exposu re to th e su rgeon an d sta [5]. How ever, position in g th e x-ray tu be above th e patien t is dan gerou s as m ost o th e scattered radiation is ref ected o th e patien t’s body tow ards th e team . Exposu re to radiation , especially scattered radiation , can be redu ced by position in g th e im age in ten si er over th e top, ie, h avin g a sh ort distan ce betw een th e im age in ten si er an d above th e patien t, an d a lon g distan ce betw een th e patien t an d th e x-ray tu be ( ig 4 ). By posi-

Image intensifier 1.2 mGy

X-ray tube

1.2 mGy

2.0 mGy

1.3 mGy

1.3 mGy

X-ray tube

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Image intensifier

Scatte re d radiation from im aging

a positioning the C arm in the re com m e nde d position be low the ope rating table , the scatte re d radiation that com e s from the x ra tube will m ostl sta unde r the table indicate d b the blue radiation cloud A ra is the ph sical uantit of radiation, with ra be ing the de posit of a oule of radiation e ne rg in a g of m atte r or tissue ith the x ra tube place d unde r the table , be twe e n and m are scatte re d towards the surge on s e e s, ste rnum , and pe lvic re gion

Positioning the x ra tube above the ope rating table and patie nt re e cts the radiation off the patie nt s bod towards the te am It also incre ase s high dose radiation rate s to the e e s ith the x ra tube in this position, the am ount of radiation that is scatte re d towards the e e s and ste rnum re gions ne arl double s ie , to m com pare d to ig 4 a

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Authors

Klaus Dre sing, os Engele n

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tion in g th e x-ray tu be below th e operatin g table th ere is th e u rth er advan tage o redu cin g h igh -dose radiation rates to th e eye len ses an d th yroid glan d by a actor o th ree or m ore [5–7].

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In lateral projection , th e su rgeon sh ou ld be on th e im age in ten si er (receiver) side becau se scattered radiation exposu re, rom th e beam h ittin g th e patien t, can be as m u ch as ten tim es less th an i on th e oth er side [6] ( ig 4 .

Scattered radiation X-ray tube

ig 4

Image intensifier

The e xposure to scatte re d radiation is approxim ate l te n tim e s le ss on the am pli e r side than the x ra tube side

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o in t p o s it io n

Join t an gu lation an d position in g o th e a ected lim b are im portan t con sideration s w h en begin n in g th e im m obilization procedu re. Depen din g on th e a ected lim b, th e patien t sh ou ld be sittin g or lyin g com ortably, w ith th e a ected lim b restin g on th e table. Speci c in orm ation on patien t position in g is ou tlin ed in each o th e dem on stration s in ch apters 15 Upper extrem ities; 16 Low er extrem ities; 17 Spin e; an d 18 Su pport ban dages.

In th e u n ction al position o a join t, th e an tagon istic m u scle grou ps are balan ced, w ith less de orm in g ten sion across th e ractu re. Addition ally, sh ou ld join t sti n ess develop, th e recom m en ded u n ction al position is th e on e th at least in ter eres w ith th e im portan t activities o daily li e. Th ere ore, im m obilization o th e join t in th e u n ction al position ben e ts u n ction al recovery. S o u ld e r p o s it io n

Wh en begin n in g im m obilization or th e sh ou lder, th e sh ou lder position sh ou ld be 80° f exion , 40° abdu ction , 20° extern al rotation , an d 20° elevation o th e orearm ( ig 4 3 ).

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Pa t ie n t p o s it io n in g

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Optim al shoulde r position for cast im m obili ation

Shoulde r in frontal plane , with

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Shoulde r in sagittal plane , with

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Shoulde r in transve rse plane , with

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e xte rnal rotation of the arm and

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

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Klaus Dre sing, os Engele n

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Th e u n ction al position o th e elbow is in 90° f exion (see ig 4 4 ). 4

Po s it io n o f p ro im a l a n d d is t a l ra d io u ln a r o in t s

Th e u n ction al position o th ese join ts is 10° pron ation (see ig 4 5 ). 5

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and

With th e th u m b, th ere sh ou ld be sligh t f exion o 15–20° in th e m etacarpoph alan geal join t an d 10° in th e in terph alan geal join t. It sh ou ld be opposed to th e n gers, rath er th an in th e sam e plan e w ith th em ( ig 4 ).

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Fu n ction al position o th e w rist is 20–30° dorsal f exion w ith u ll st closu re possible ( ig 4 6 ).

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ig 4 5 unctional position of the radioulnar oints

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Po s it io n o f fin ge rs II

6 3 In t rin s ic p lu s p o s it io n

Th e u n ction al position o th e m etacarpoph alan geal (MCP) join ts is 45–50° f exion w ith th e in terph alan geal (IP) join ts in 20 to 30° f exion . Th e n gers are position ed as i th ey are h oldin g a bottle ( ig 4

Th e in trin sic-plu s position allow s better preservation o n ger u n ction , particu larly regardin g m etacarpoph alan geal f exion ran ge, th an th e previou sly described u n ction al position . In th e in trin sic-plu s position , th e MCP join ts are in 70–90° f exion w ith th e IP join ts in exten sion . Th is places th e collateral ligam en ts o th e MCP join ts u n der ten sion so th ey do n ot con tract w h ile im m obilized. Th e proxim al in terph alan geal an d distal in terph alan geal join ts, im m obilized in u ll exten sion , h ave less risk o developin g f exion con tractu res ( ig 4 ). Rotation al align m en t o m etacarpal o proxim al ph alan geal ractu res is correct i all in ju red n gers poin t to th e scaph oid in f exion ( ig 4 ).

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Intrinsic plus position of nge rs for cast im m obili ation

Corre ct position of nge rs and hand for cast im m obili ation

In e xte nsion of the proxim al inte rphalange al PIP oints, the collate ral ligam e nts are without te nsion and would shorte n during im m obili ation in this position c In e xion of the PIP oints, the ligam e nts are unde r te nsion and will not shorte n during im m obili ation in this position Acce ssor collate ral ligam e nt

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Collate ral ligam e nt Phalango gle noidale ligam e nt

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

For th e th u m b carpom etacarpal (trapeziom etacarpal or saddle join t), th e u n ction al position is w ith th e th u m b opposed, as w h en you are h oldin g a bottle. ip p o s it io n

Th e u n ction al position o th e kn ee in a cast is 10–20° lexion . In a w eigh t bearin g cast, kn ee f exion sh ou ld be closer to 10° in order to ach ieve better w alkin g u n ction . n le p o s it io n

For th e an kle, a u n ction al position correspon din g to 90° f exion is advised. Keep in m in d th at w h en relaxed, th e oot alls in to th e “drop oot” position (su pin ation an d plan tar f exion ). It is im portan t to preserve a plan tigrade oot position , w ith th e plan tar su r ace parallel to th e grou n d w h en th e tibia is u prigh t.

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10°–20°

90° 90°

ig 4 scaphoid

Corre ct rotation In e xion, all nge rs point to the

ig 4 unctional position of hip, ne e , and lowe r le g for cast imm obili ation

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In stan din g position , all join ts o th e oot are in th e u n ction al position . le in e r t

In “dyn am ic splin tin g” (see ch apters 15.21 Klein ert dyn am ic splin t u sin g plaster o Paris; an d 15.22 Klein ert dyn am ic splin t u sin g syn th etic, com bicast tech n iqu e) th e position o th e join ts are ch an ged in com parison to th e u n ction al position . Th is special splin t avoids f exor ten sion w h ile allow in g m otion as th e digit is actively exten ded again st elastic resistan ce. With relaxation o exten sors, th e elastic passively restores n ger f exion .

in ge rs II

In cases o ten don f exion in ju ries o th e n gers, dyn am ic Klein ert splin tin g is carried ou t in a 30–40° w rist position an d 50–70° in ger lexion ( ig 4 3 ).

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n a m ic s p lin t in g a ft e r

In cases o ten don f exion in ju ries o th e th u m b, dyn am ic Klein ert splin tin g is carried ou t in a 30° w rist position an d 30° position o th e basic join t an d th u m b en d join t ( ig 4 ).

30°–40°

50°–70°

30° 30°

ig 4 Position of thum b and wrist for d nam ic Kle ine rt splint ing in case s of te ndon e xion in ur of the thum b

ig 4 3 Position of the nge rs and wrist for d nam ic Kle ine rt splinting afte r e xor te ndon re pairs

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

p p l in g p la s t e r o f Pa ris

Be ore begin n in g th e castin g procedu re, prepare a con tain er o w ater at room tem peratu re (at or arou n d 20° C). Th e correct w ater tem peratu re is im portan t to avoid allow su cien t tim e or cast application , an d to excessive h eat an d du e to th e n orm al exoth erm ic reaction o th e settin g cast (see ch apter 6 Properties o cast m aterials) . A h igh er tem peratu re o th e dippin g w ater w ill accelerate settin g, an d sh orten m oldin g w orkin g tim e. In creased h eat w ith in th e cast m igh t resu lt in bu rn in ju ries. Fu rth erm ore, in h ot w ater, plaster w ill detach rom th e textile layer or dissolve in to th e w ater, a process th at w ill resu lt in redu ced stability ( ig 4 4 ). It m u st also be rem em bered th at th at cast th ickn ess also con tribu tes to h eatin g o a settin g cast. Th u s th e m ore cast layers th at are u sed, th e h igh er th e tem peratu re du rin g settin g. Water in th e cast basin or sin k sh ou ld be clean an d ch an ged rou tin ely several tim es du rin g th e day.

ig 4 5 olding the POP roll corre ctl during the dipping pro ce ss allows ou to uic l ide ntif the fre e e nd of the roll, and be gin appl ing the cast

a ig 4

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Cast basin with re sidue s of plaste r m ate rial

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Rolled plaster ban dages w ill becom e w et rapidly i su bm erged in to w ater in th e correct w ay. Th e best w ay is to h old th e POP roll betw een th u m b an d n gers du rin g th e dippin g process ( ig 4 5 ), w ith th e axis o th e roll m ore or less vertical in th e w ater. Th e POP ban dage roll lies in th e palm o th e h an d, th e th u m b rests on th e roll w ith ou t m u ch pressu re, w h ile th e ree en d o th e ban dage is su pported by th e lon g n gers. Th is w ay “th e eyes can look in to th e ban dage” as it is u n rolled on to th e patien t’s lim b ( ig 4 6 Dippin g th e plaster roll w ith ou t leavin g th e rst layer ree cau ses th e cast layers to stick togeth er, an d in ter eres w ith iden tiyin g th e ree en d ( ig 4 ).

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Th ere are pron ou n ced di eren ces am on g POP, rigid syn th etic, an d sem irigid syn th etic cast m aterials (see ch apter 6 Properties o cast m aterials). Th ese di eren ces a ect both th e application process an d th e en d resu lt.

Pla s t e r o f Pa ris ro ll

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ig 4 6a The care give r m ust be able to loo into the space be twe e n the roll and the e nd be ing wrappe d around the patie nt

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Overvie w of cast, splint, orthosis, and bandage te chni ue s

Wh en dippin g plaster rolls, th e depth o th e w ater sh ou ld be at least 20–30 cm . Wh en rolls are dipped as described above, air bu bbles w ill escape th rou gh th e core o th e roll, allow in g th e w ater to satu rate all layers o plaster u n i orm ly. A ter a ew secon ds, w h en th e bu bblin g ceases, th e plaster is adequ ately w et ( ig 4 ). A gen tle squ eeze elim in ates excess w ater ( ig 4 ). Th en , th e ree en d is applied to th e patien t’s lim b an d th e roll m aterial is w rapped on to th e lim b w h ile th e roll itsel rem ain s in con tact w ith th e cast paddin g. Plaster o Paris rolls are applied u sin g th e h al overlappin g tech n iqu e (see topic 10 Ban dagin g tech n iqu es) so th at at least h al o each precedin g w rap is covered by th e ollow in g tu rn . Wh en rollin g plaster over an an gled region , or exam ple th e an kle join t, plaster overlaps h al w ay over th e h eel w h ile m u ch greater overlappin g is accepted an teriorly.

ig 4 Plaste r roll that was dippe d incorre ctl , without e e ping the e nd fre e

ig 4 If dippe d corre ctl into bubble s e scape from the POP roll

ig 4

cm wate r de pth, air

Slight s ue e ing of the we t POP roll

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

Pla s t e r o f Pa ris s p lin t s lo n gu e t t e s

Dry spots or dry POP layers redu ce th e qu ality an d stren gth o th e cast. In su cien tly soaked plaster w ill resu lt in delam in ated, u n com pou n ded plaster, resu ltin g in so-called pu pastry plaster ( ig 4 3 3 ).

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Plaster o Paris splin ts (lon gu ettes) are olded an d dipped in to w ater at an an gle o 45° in order to let th e air bu bbles escape ( ig 4 3 ). A w ater colu m n o 20–30 cm produ ces en ou gh pressu re to expel air bu bbles rom betw een th e layers. Th e im m ersion tim e is approxim ately 3 secon ds or u n til bu bblin g ceases. Th e excess w ater is th en squ eezed ou t as it is w ith plaster rolls ( ig 4 3 ). Hold each en d separately, so th at th ey can readily be separated to preserve correct align m en t o th e splin t layers.

Th e layers o th e splin t (lon gu ette) are n ow stu ck togeth er by m an u al lon gitu din al com pression “m assage” on a f at, easily clean able su r ace o a cou n ter or th e cast cart ( ig 4 3 ).

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Dipping the dr folde d POP splint longue tte into

ig 4

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Slight s ue e ing of the we t POP splint longue tte

ig 4 3 Splint longue tte is stre tche d and sm oothe d out, m olding the la e rs toge the r and re le asing the air bubble s trappe d inside the mate rial

ig 4

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Puff pastr plaste r

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A ter h avin g sm ooth ed th e plaster splin ts (lon gu ettes), th ey are applied w h ere desired, an d th e sm ooth in g process is repeated m an u ally on th e extrem ity, ru bbin g th em in to previou sly applied plaster, or on to th e paddin g i an en dprodu ct splin t rath er th an a circu m eren tial cast is in ten ded. Th is sm ooth in g process sh ou ld resu lt in w rin kleless POP cast m aterial, position ed as ch osen on th e extrem ity, w h ich rem ain s in th e desired u n ction al position w ith ou t w rin kles or w eak spots in th e plaster, an d w ith ou t irregu larities in th e paddin g. Wh ile th e plaster is still so t, it is m olded to th e extrem ity, w ith sm ooth broad appropriately located pressu re su r aces to m ain tain ractu re redu ction an d lim b align m en t.

p p l in g s n t e t ic

Syn th etic cast m aterial is n orm ally (accordin g to its accom pan yin g in stru ction s) dipped in to cold w ater at room tem peratu re o arou n d 20 degrees. How ever, syn th etic m aterial can actu ally be applied eith er wet, or u sin g a dry application tech n iqu e. e t a p p lica t io n

With th e stan dard wet application , dip th e syn th etic m aterial in to water with an im m ersion tim e o approxim ately 3 secon ds an d a water depth o 20–30 cm . Su bm ergin g th e m aterial in water begin s th e polym erization process ( ig 4 35 .

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Overvie w of cast, splint, orthosis, and bandage te chni ue s

Du rin g th e application an d m oldin g o POP, avoid creatin g n ger-tip pressu re poin ts (in den tation s) by u sin g on ly th e h eel an d f at su r ace o th e h an d (“f at h an d tech n iqu e”) ( ig 4 3 4 ).

a ig 4 3 4 lat hand te chni ue Corre ct m anne r of appl ing and m olding the plaste r b onl using the he e l of the palm , not the nge rs

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ig 4 35 a Dipping s nthe tic m ate rial in wate r starts the po l m e ri ation proce ss

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

r a p p lica t io n

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Th e th ickn ess (n u m ber o cast m aterial layers) requ ired depen ds on th e ollow in g: • Th e castin g m aterial u sed (POP or syn th etic) • Th e patien t’s w eigh t • Body region (low er or u pper extrem ity an d an ticipated loadin g) • Expected patien t com plian ce.

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Syn th etic m aterial can also be applied dry, w ith ou t previou s dippin g in to w ater. Th is in creases th e w orkin g tim e, be ore th e cast can n o lon ger accept m oldin g. Th is application tech n iqu e is recom m en ded or in experien ced u sers or in com plex cases w h ere m ore tim e is n eeded, as w ell as on occasion s w h en an assistan t is n ot available. A ter dry application o syn th etic cast m aterial, polym erization can be accelerated by w rappin g th e cast tem porarily w ith a w et elastic cloth ban dage ( ig 4 3 6 ). Like POP, syn th etic cast rolls are applied u sin g th e h al -overlappin g tech n iqu e.

Nu m e r o f ca s t m a t e ria l la e rs

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Body region

Number of layers for plaster of Paris cast material

Number of layers for synthetic cast material

Upper extremity

8–10 layers

4–6 layers

Lower extremity

8–10 layers

6–8 layers

Ta le 4 5 a Num be r of cast mate rial la e rs within a cast in re lation to bod re gion

Body region

Number of layers for plaster of Paris cast material

Number of layers for synthetic cast material

Upper extremity

8–10 layers

6–8 layers

Lower extremity

12–16 layers

9–12 layers

Ta le 4 5 Num be r of cast mate rial la e rs within a splint in re la tion to bod re gion

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ig 4 a

36a c

Dr application of s nthe tic

S nthe tic cast m ate rial be ing applie d using a dr application

c Afte r appl ing the s nthe tic m ate rial, an e lastic bandage can be dippe d in wate r, the n wrappe d around the mate rial to acce le rate the se tting

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Overvie w of cast, splint, orthosis, and bandage te chni ue s

Trim m in g a n d m o ld in g o f ca s t e d ge s

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o r in g a n d s e t t in g t im e

Th e len gth o a cast or splin t sh ou ld be en ou gh or optim al su pport, w ith ou t im pin gin g on th e f exed su r ace o an adjacen t n on im m obilized join t. Th e adequ ate len gth o splin ts an d casts h as to be determ in ed in order to avoid in su cien t im m obilization on on e side an d u n n ecessary restriction o join t m otion on th e oth er side ( ig 4 3 ). By oldin g back th e paddin g an d tu be ban dage, sm ooth edges w ill resu lt, w h ich w ill protect both so t tissu es an d bon es rom pressu re an d sh arp edges ( ig 4 3 ).

An overview o w orkin g an d settin g tim es or POP an d syn th etic cast m aterials is provided in Ta le 4 6 . Wh en u sin g dry syn th etic m aterial, th e settin g tim e can be sh orten ed by w rappin g a w et ban dage arou n d th e dry cast or splin t in order to speed u p th e polym erization rate.

ig 4 3 he n appl ing a cast, oint m otion should be possible without an re striction During e xion, a gap of two nge rs bre adth approxim ate l cm should e xist be twe e n the proxim al cast and the proxim al lim b se gm e nt, as shown he re for the e lbow On the e xte nsor side , the cast can approach the oint line , but still should be che c e d for im pinge m e nt with the oint in full e xte nsion

ig 4 3 olding the padding and the tube bandage bac ove r the e dge of the cast re sults in sm ooth padde d e dge s and prote cts the soft tissue during m otion

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Type of cast material / application

Working time

Setting time

Weight bearing permissible after

Plaster of Paris

3–5 minutes1

10–12 minutes2

24–48 hours3 (if allowed)

Wet application

2–4 minutes

6-8 minutes

30 minutes

Dry application

5–7 minutes

8-10 minutes

30 minutes

Synthetic cast material:

e ge nd De pe nding on wate r te m pe rature and cast m ate rial brand or the initial pe riod of harde ning Com ple te pe riod of tim e for se tting and possibilit of we ight be aring de pe nds on the thic ne ss of the cast or splint Ta le 4 6 Ove rvie w of wor ing and se tting tim e s for POP and s nthe tic cast m ate rials

6

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Som etim es it is in dicated to cu t a “w in dow ” in to th e cast to perm it w ou n d exam in ation an d care w h ile th e cast is m ain tain ed on th e lim b ( ig 4 3 ). A ter m arkin g th e w in dow , an d cu ttin g th e h arden ed cast w ith a saw , th e cast w in dow an d paddin g are rem oved, an d th e tu be ban dage is cu t to allow access to th e w ou n d. Th e tu be ban dage can be tu rn ed back over th e w in dow edges to secu re th e rem ain in g paddin g. A ter treatm en t an d dressin g o th e w ou n d, th e cast segm en t th at w as rem oved is repadded, an d replaced in to th e w in dow , to cover th e w ou n d an d apply u n i orm gen tle pressu re to m in im ize sw ellin g o so t tissu es in to th e w in dow (w in dow edem a). Th e w in dow cover is secu red w ith elastic or adh esive ban dage, w ith th e goal o restorin g u n i orm pressu re over th e w in dow ed area. Plastic oam paddin g, w ith adh esive backin g, i available, is ideal or th is pu rpose. I a cast w in dow is desired, it m u st be position ed per ectly over th e w ou n d, an d large en ou gh to perm it dressin g rem oval an d reapplication . Plan n in g ah ead w ill in clu de an appropriately sized an d applied dressin g, an d o ten a bu m p or m ou n d o rolled cast paddin g over th e dressin g so it is easily located be ore th e w in dow is cu t. Too large a w in dow w eaken s a cast, especially i w ou n d drain age is sign i can t. Stren gth an d patien t com plian ce can be au gm en ted by overw rappin g th e w in dow w ith cast m aterial (plaster or syn th etic). To avoid its adh eren ce to th e u n derlyin g cast, a layer o cast paddin g can be applied rst. Th is perm its rem oval o th e overw rap w ith a cast saw , w ith ou t addin g u n desirable addition al cast th ickn ess, or w eaken in g th e cast by tryin g to n d th e covered w in dow .

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Planning of the fenestration and marking with a felt tip marker or wax crayon.

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a Cutting of the cast window with the oscillating cast saw.

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Ca s t fe n e s t ra t io n

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Klaus Dre sing, os Engele n

Using a cast knife to lever out the cast window.

c View of the soft tissue after removing padding and undercast material. The wound can now be examined and the treatment can take place.

d Swelling of the soft tissue results in a window edema. The photograph shows blanched areas of skin suggesting impaired perfusion.

e This image shows the window edema preventing the reinsertion of the cast window to the same level (niveau) of the adjacent cast material.

f ig 4

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Cast fe ne stration to vie w soft tissue s during casting

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Overvie w of cast, splint, orthosis, and bandage te chni ue s

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Ba n d a gin g t e c n i u e s

Cris s cro s s t e c n i u e

Th e m ost com m on ban dage w rappin g tech n iqu es in clu de th e ollow in g: • Hal -overlappin g tech n iqu e • Criss-cross tech n iqu e • Stretch -relax tech n iqu e • Figu re-o -eigh t w rappin g tech n iqu e.

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Elastic ban dages an d castin g m aterials are o ten applied u sin g th e h al -overlappin g tech n iqu e, w h ere th e ban dage is overlapped by abou t h al o its w idth on each w rap. Wh en applyin g th e h al -overlappin g tech n iqu e (see ig 4 4 ) th e so t tissu es are com pressed in order to decrease sw ellin g an d edem a.

ig 4

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The half ove rlapping te chni ue

Th e criss-cross tech n iqu e is u sed on a tapered extrem ity, w h ere th ere is an in creasin g or decreasin g diam eter as you progress proxim ally or distally alon g a lim b. Begin by an ch orin g th e ban dage, th en w rap arou n d th e extrem ity at a sligh t an gle aw ay rom th e join t or in ju ry. Head back tow ards th e join t m ovin g above th e previou s level o w rappin g, th en again w rap dow n aw ay rom th e join t at a sligh t an gle be ore m ovin g u p again . Slow ly, you m ake you r w ay u p th e lim b, rom sm aller to larger diam eter ( ig 4 4 ). Th is tech n iqu e is ideal or providin g com pression w h en th ere are variation s in th e circu m eren ce o th e extrem ity, an d is th ere ore e ective or lon ger (see ch apter 18.4 Wrist ban dage).

ig 4 4 tre m itie s

Criss cross bandage te chni ue use d for tape re d e x

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Th e stretch -relax tech n iqu e is u sed or syn th etic cast m aterial. Firstly, by pu llin g th e m aterial rom th e roll, th e ten sion is released. Th en , with ou t th e ten sion , th e ban dage is applied on to th e extrem ity or u n derlyin g layers o syn th etic cast m aterial ( ig 4 4 ). Usin g too m u ch ten sion wh ile applyin g th e syn th etic m aterial w ou ld resu lt in th e cast bein g too tigh t.

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igu re o f e ig t t e c n i u e

Th e gu re-o -eigh t tech n iqu e is u sed to w rap a join t at an an gle, an d is prin cipally u sed or th e elbow , kn ee, or an kle join t. On ce an ch ored (circu lar w rap) below th e join t, th e ban dage is applied diagon ally an d an ch ors to th e lim b above th e join t, be ore retu rn in g to its origin . Th is step is repeated, m akin g a gu re o eigh t sh ape. Th is tech n iqu e provides su pport w h ile still allow in g m ovem en t in th e join t. Th e m ost requ en t in dication or an elastic ban dages is th e ban dage o th e an kle join t, an d at th is location , th e gu reo -eigh t tech n iqu e is recom m en ded. Th e com plete an kle w rappin g tech n iqu e is described in detail in ch apter 18.6 An kle an d oot ban dage ( ig 4 4 3 ).

ig 4

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Stre tch re lax te chni ue for s nthe tic cast mate rials

4 4 3 The gure of e ight te chni ue provide s support but avoids e xce ssive m ate rial at the oint

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Overvie w of cast, splint, orthosis, and bandage te chni ue s

Böh ler w as th e rst to em ph asize th e n eed or splittin g casts com pletely in prim ary ractu re care [8]. In prim ary care, POP an d syn th etic casts are alw ays split com pletely to en su re th at sw ellin g can be accom m odated. Th e location o th e split sh ou ld be plan n ed be ore th e cast is cu t. I possible, avoid splittin g over bon y prom in en ces. A good m an n er is to rst m ark th e lin e w ith a elt or grease pen (on POP casts on ly) or a perm an en t m arker ( ig 4 4 4 ).

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Ca s t s p lit t in g t e c n i u e s a n d ca s t re m o va l

ig 4 4 4 m ar e r pe n

In sem irigid syn th etic casts, th e cast is split w ith scissors. In m ost rigid syn th etic or POP casts, th e u se o a cast saw is recom m en ded ( ig 4 4 5 ). How ever, th e paddin g an d u n derlyin g lin in g m aterial (ie, tu be ban dage) are th en com pletely cu t u sin g scissors ( ig 4 4 6 ). s cilla t in g ca s t s a

Wh en u sin g th e oscillatin g cast saw or eith er cast splittin g or or perm an en t rem oval at th e en d o treatm en t, it is im portan t to explain to th e patien t h ow th e cast saw w orks as th e blade an d saw design can terri y som e patien ts, an d th e lou d n oises can be righ ten in g or ch ildren . A good saw in g tech n iqu e an d ear protectors or th e patien t can greatly redu ce patien t an xiety. Cast saw blades, especially i du ll, can becom e h ot, an d bu rn s as w ell as laceration s are possible. I th e patien t com plain s o pain , saw in g sh ou ld be stopped im m ediately, an d th e u n derlyin g skin assessed, alon g w ith th e blade tem peratu re. Very care u l resu m ption o saw in g m ay, o cou rse, be requ ired to expose th e possibly in ju red area.

e fore splitting the cast, m ar the splitting line with a

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Cast saw be ing use d to split a le g cast

ig 4 4 6 scissors

Cutting the padding and unde rl ing lining m ate rial with

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

ig 4 4 ifting the saw blade , rotating the blade slightl b hand, the n re appl ing the saw furthe r along the cast gre atl re duce s he at ge ne ration

ig 4 4 The saw blade oscillate s and doe s not rotate , so the ris of s in in ur is re duce d

e i

To split or rem ove th e cast, ollow th ese steps: 1 Train in g: Th e u se o a cast saw is on ly perm itted or train ed person al. 2 Heat: Use a sh arp saw blade as a blu n t blade w ill get h ot m u ch aster. 3 Rotate th e blade: Du e to th e vibration s th at occu r w ith in th e rigid m aterial, th e blade w ill get h ot an d can cau se bu rn in g stripes. Th is e ect is redu ced/ avoided i a sh arp saw blade is u sed an d w h en th e saw blade in m an u ally tu rn ed sligh tly by th e saw operator, a ter each step o cu ttin g. With th is procedu re, an oth er part o th e blade is u sed or cu ttin g resu ltin g in less h eat at th at part o th e blade. 4 Gen tle application : Apply th e saw blade w ith a little pressu re on th e cast. Use th e opposite h an d or th e n gers o th e ipsilateral h an d or depth regu lation . 5 Bon y prom in en ces: En su re th e cu ttin g lin e is n ot over bon y prom in en ces (eg, m alleolu s or styloid process o radiu s or u ln a). 6 Paddin g: Th e paddin g an d tu be ban dage are cu t w ith blu n t-tipped ban dage scissors. 7 Bivalvin g: Som etim es it is n ecessary to cu t th e cast at tw o sides (bivalve it) in order to m ake rem oval/ open in g easier an d less h arm u l to th e patien t. Care u l placem en t o th e tw o cu ts is n ecessary to en su re easy rem oval an d preservation o th e cast i its reapplication is in ten ded.

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An oscillatin g saw blade does n ot rotate like a circu lar saw bu t in stead vibrates rapidly w ith very little rotation . Th e vibration s or oscillation s are still en ou gh to allow th e blade to cu t th e rigid cast/ plaster m aterial. Wh en th e saw gets th rou gh th e cast, th e tech n ician w ill eel less pressu re du e to th e so t u n derlyin g cast paddin g. At th at m om en t, th e saw sh ou ld be li ted, m an u ally rotated sligh tly, an d reapplied u rth er alon g th e cast ( ig 4 4 ). With th is tech n iqu e, th ere is less risk o bu rn s or skin dam age, bu t th e risks are n ot en tirely elim in ated, particu larly i th e skin is dystroph ic, as w ith som e elderly patien ts, or th ose receivin g h igh doses o adren o-cortical steroids. It is, h ow ever, h igh ly recom m en ded to dem on strate th e saw h arm lessly tou ch in g th e skin o th e operator ( ig 4 4 .

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I con siderable sw ellin g is expected du rin g prim ary ractu re care, a strip is cu t ou t o th e cast ( ig 4 4 ). A ter com plete splittin g o th e u n derlyin g layers o paddin g an d tu be ban dage, th e gap is lled w ith paddin g in order to avoid gap edem a (sim ilar to w in dow edem a). Th e cast is th en w rapped w ith elastic ban dage.

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4 a e

e m oving a strip of cast

a Splitting and re m oval of cast m ate rial, padding, and tube bandaging c d The re sulting gap is re lle d with padding e The cast is the n wrappe d with an e lastic bandage

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Authors

Klaus Dre sing, os Engele n

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Wh en cu ttin g sem irigid casts, squ eeze th e cast by pressin g on both sides to bu lge th e cast aw ay rom th e patien t, as sh ow n . Th is provides space to in sert scissors an d h elps avoid in ju ry to th e patien t’s skin an d so t tissu es ( ig 4 5 ). e fi in g t e ca s t

A ter splittin g o th e cast, th e cast is closed ( xed) w ith an elastic ban dage ( ig 4 5 ).

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In special situ ation s, it is advisable n ot to split th e cast com pletely all at on ce bu t to split an d x th e cast in stages (stepby-step) in order to avoid a ectin g th e ractu re redu ction . Th is in volves cu ttin g a part o th e cast, th en w rappin g th at section w ith ban dage, th en cu ttin g a little m ore o th e cast, ollow ed by a little m ore ban dagin g, etc. ig 4 5 sh ow s th e step-by-step splittin g an d xin g tech n iqu e.

a

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ig 4 5 a split cast

Appl ing the e lastic xation bandage around the

b ig 4 5 a Pre ssing on both side s of the cast with the hand cre ate s a sm all bulge for inse rting the scissors

ig 4 5 The ste p b ste p splitting and xing te chni ue he lps to pre ve nt loss of re duction

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Overvie w of cast, splint, orthosis, and bandage te chni ue s

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Pa t ie n t in fo rm a t io n

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Th e su rgeon sh ou ld in orm th e patien t abou t th e diagn osis an d treatm en t option s, as w ell as provide su cien t, speci c in orm ation abou t an y plan n ed in terven tion (see topic 6 in ch apter 3 Prin ciples o castin g). Be ore leavin g th e em ergen cy departm en t, th e patien t sh ou ld receive in orm ation on h ow to deal w ith poten tial problem s or com plication s related to th e in ju ry an d its treatm en t, in clu din g th e cast or ban dage (see topic 11 in ch apter 3 Prin ciples o castin g). A w ell-accepted m eth od is to give th e patien t n ot on ly verbal bu t also w ritten in orm ation (Appen dix 1) be ore h e or sh e leaves th e treatm en t cen ter. Th is sh ou ld in clu de in stru ction s or w h en an d h ow to call or h elp sh ou ld an y problem s arise.

e vie

and assessment

Th e day a ter application o th e cast, a m edical review is m an datory. It is very im portan t th at th e ollow in g item s are ch ecked: • Circu lation w ith – Pu lse assessm en t – Capillary re ll assessm en t • Sen sation • Motor u n ction • Sw ellin g • Level o pain .

Patien ts sh ou ld be sch edu led to retu rn th e ollow in g day or cast review an d re-assessm en t.

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Klaus Dre sing, Pe te r Trafton

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Su m m a r

• Ph ysician s respon sible or selectin g an d m an agin g n on operative ractu re care sh ou ld also be able to apply an y cast, splin t, orth osis, or su pport ban dage th em selves • In prim ary ractu re care, a splin t is o ten in itially u sed a ter redu ction o th e ractu re becau se o th e likelih ood o so t-tissu e sw ellin g; th e splin t can later be replaced w ith a cast • Prim ary de n itive ractu re care occu rs w h en , in special circu m stan ces, th e in itial cast or splin t does n ot n eed to be replaced • Be ore applyin g an y orm o im m obilization ban dage, th e caregiver sh ou ld h ave a th orou gh u n derstan din g o th e properties, recom m en ded sizes, w orkin g an d settin g tim es, an d w rappin g an d cu ttin g tech n iqu es or th e variou s types o paddin gs an d castin g m aterials • Be ore con du ctin g an im m obilization procedu re, th e caregiver sh ou ld be u lly prepared w ith th e relevan t m aterials, castin g an d m on itorin g equ ipm en t, in stru m en tation , an d ideally, a speci c cast room • Apart rom th e actu al ban dagin g tech n iqu es, th e su rgeon is also respon sible or oth er im portan t elem en ts in clu din g pain relie , ractu re redu ction , patien t in orm ation an d con sen t, an d review s an d assessm en t post-im m obilization • On ly w h en th e su rgeon h as th e u ll u n derstan din g o per orm in g n on operative im m obilization can h e or sh e con den tly assess th e casts applied by residen ts, cast tech n ician s, or oth er caregivers.

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Th e du ration o im m obilization varies depen din g on th e type o ractu re or in ju ry, patien t’s age, i su rgery w as in volved, join t stability, an d patien t com plian ce. More speci c in orm ation on du ration o im m obilization is provided in th e ch apters o section 2 Gu idelin es.

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e fe re n ce s

1. B a t ia , o u s d e n P . Red isplacem en t o paed iatric orearm ractu res: role o plaster m ou ld in g an d padd in g. Injury. 2006 Mar; 37(3):259 – 268. 2. Bo d S, Be n a m in , s p lu n d C. Prin ciples o castin g an d splin tin g. Am Fam Physician. 2009 Jan 1; 79(1):16 –22. 3. Bro n C, le in , e is C , e t a l . Em ergen cy departm en t an algesia or ractu re pain . Ann Emerg Med. 2003 Au g; 42(2):197–205.

4. C a rn le . The Closed Treatment of Common Fractures. 4th ed. Un ited Kin gdom . Cam bridge Un iversity Press; 2010. 5. re s in g . In traoperative im agin g. Babst R, Bavon ratan avech S, Pesan tez R (eds). Minimally Invasive Plate Osteosynthesis. 2n d ed. Stu ttgart New York: Georg Th iem e Verlag; 2012:75 –88.

6.

a m p e rs a u d , o le T, S e n C, e t a l . Radiation exposu re to th e spin e

su rgeon du rin g f u oroscopically assisted ped icle screw in sertion . Spine. 20 00 Oct 15; 25(20):2637–26 45. 7. u c s , Sc m id , it e l rge T, e t a l . Exposu re o th e su rgeon to rad iation du rin g su rgery. Int Orthop. 1998, 22(3):153-156. 8. B le r . [The Treatment of Fractures]. 9th –11th ed. Wien : Wilh elm Mau d rich ; 1943. Germ an .

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Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

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In t ro d u ct io n e a d in gs a n d in s t ru ct io n s Indications and goals E uipm e nt list Pe rsonne l Patie nt positioning Spe cial things Proce dure inal asse ssm e nt Cast splitting, cast re m oval 3

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

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e a d in gs a n d in s t ru ct io n s

In th e ollow in g ch apters (ch apters 15 to 18) a total o 55 cast, splin t, orth osis, an d su pport ban dage procedu res are dem on strated. Each dem on stration provides a w ide ran ge o in orm ation ou tlin in g th e preprocedu re plan n in g, stepby-step im m obilization in stru ction s, an d postprocedu re review an d assessm en t. In m ost cases, a u n i orm sequ en ce an d stru ctu re o presen tation is u sed in th ese dem on stration s in order to acilitate re eren ce an d u n derstan din g. How ever, n ot all dem on stration s con tain th e sam e in orm ation , or exam ple, addition al in stru ction s on cast rem oval are in clu ded w h en it is an especially sen sitive procedu re, an d altern ative steps are som etim es in clu ded or th e sam e procedu re w h en th is is con sidered appropriate. Neverth eless, th e topics an d su bject h eadin gs u sed in each dem on stration clearly ou tlin e th e steps requ ired or each procedu re.

Th e 55 im m obilization dem on stration s typically com prise th e ollow in g topic h eadin gs an d in orm ation : • • • • • • • •

In dication s an d goals Equ ipm en t list Person n el Patien t position in g Special th in gs to keep in m in d Procedu re Fin al assessm en t Cast splittin g an d/ or cast rem oval

To u rth er su pport learn in g, a n u m ber o im ages an d graph ics h ave been added th rou gh ou t each dem on stration . Th ese addition al elem en ts are in th e orm o pictograph s, 3-D illu stration s, or sn ap sh ots rom th e actu al dem on stration video an d are particu larly u se u l to sh ow com plex procedu res, th e recom m en ded lim b an d patien t position in g an gles, or to provide oth er view in g an gles in addition to th e cam era.

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In d ica t io n s a n d go a ls

In each dem on stration , th e in dication s an d goals o treatm en t are presen ted. IN IC TI N

As an addition al aid to learn in g, a pictograph h as also been developed to represen t th e a ected body region ( ig 4 ). Th is im age is placed on th e top righ t h an d side o th e ch apter pages to assist w ith speedy re eren cin g.

• Stabilization o th e orearm an d elbow

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• Fractu re o th e orearm or elbow • Epicon dylitis

Addition ally, a pictu re o th e en d resu lt o th e im m obiliza). tion procedu re is sh ow n ( ig 4

ig 4

Cast im age

ig 4

Pictograph indicating the

affe cte d lim b

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

u ip m e n t lis t

3

An equ ipm en t list an d ph otograph o all m aterials n eeded or th e cast, splin t, orth osis, or su pport ban dage is provided. Th is in orm ation ou tlin es w h eth er plaster o Paris or rigid or sem irigid syn th etic castin g m aterials are to be u sed. All oth er m aterials an d equ ipm en t, in clu din g paddin g, tu be ban dages, an d an y f xin g m aterials su ch as velcro or tape etc are also listed an d sh ow n ( ig 4 3 ).

Pe rs o n n e l

For each dem on stration , th e n u m ber o person n el requ ired to apply th e im m obilization ban dage is in dicated w ith a n u m ber an d a pictograph . A pictograph o a person w ith a steth oscope in dicates a train ed ph ysician / su rgeon is requ ired. A person w ith n o m arkin gs in dicates a cast tech n ician / caregiver is su itable.

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Th ese sym bols acilitate qu ick u n derstan din g o w h o is requ ired ( ig 4 4 ).

IP

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Cast padding Plaste r of Paris splint or cm 3

Tube bandage

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Cre pe pape r bandage

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Elastic bandage

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au e bandage

cm,

cm,

cm in dispe nse r box

Cut tube bandage Scissors

ig 4

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E uipm e nt and m ate rials

1 1 2 a

b

ig 4 a

4a c

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Pe rsonne l

surge on is ne e de d cast te chnician care give r is ne e de d

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surge on and

cast te chnician care give r are ne e de d

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Ove rvie w of cast, splint, orthosis, and bandage te chni ue s—dem onstration format and icons

Pa t ie n t p o s it io n in g

5

Th e position in g o th e patien t is presen ted in a 3-D illu stration an d described in detail ( ig 4 5 ).

Sp e cia l t in gs

A list o special item s to keep in m in d w h ile per orm in g th e procedu re is listed ( ig 4 6 ). For exam ple, th ese m igh t in clu de su ch th in gs as en su rin g th e protection o bon y prom in en ces, review in g circu lation , or en su rin g th at th e cast or splin t m aterial does n ot in ter ere w ith th e n orm al m ovem en t o th e rest o th e lim b.

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P SITI NIN

SP CI

Place the affe cte d lim b on the table , in a functional position, with e xion of the e lbow

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Patie nt and lim b positioning

P IN

IN

• Th e distal palm ar crease sh ou ld rem ain ree • Protection o th e lateral an d m edial epicon dyle • Protection o th e olecran on • Wh ile th e splin t is settin g, th e lim b sh ou ld be position ed h al w ay betw een su pin ation an d pron ation

Se at the patie nt com fortabl on a stool

ig 4

T IN S T

ig 4

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Spe cial things

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

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Klaus Dre sing, os Engele n

Pro ce d u re

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A ter th e equ ipm en t list an d patien t preparation h ave been ou tlin ed, th e dem on stration s th en give a step-by-step ou tlin e o th e procedu re th at m u st take place ( ig 4 ). Th e procedu re section in each dem on stration is regu larly su pported w ith addition al pictu res an d illu stration s, w ith each n ew step providin g its ow n clear descriptive text.

Man y o th e dem on stration s u se com m on steps an d tech n iqu es ( or exam ple, th e h al -overlappin g tech n iqu e or w rappin g, or th e dippin g process or w ettin g cast m aterial). Rath er th an provide a len gth y explan ation on th ese elem en ts in each dem on stration , u rth er in orm ation on th ese com m on tech n iqu es (in clu din g w orkin g tim es, layers o m aterial, an d w rappin g tech n iqu es) can be ou n d in ch apter 14.1 Overview o cast, splin t, orth osis, an d ban dage tech n iqu es.

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Authors

Appl a la e r POP splint on the dorsal side for e xtra stabilit

Subm e rge the splint in wate r for a fe w se c onds, re m ove , and s ue e e out the e xce ss wate r

Position the splint and cut at the e lbow to allow ove rlapping

Sm ooth out the splint

Stre tch and smooth out the splint, pre ssing the la ers toge the r, re sulting in a compact splint If this proce dure is not done, puff pastr plaste r will re sult, causing an unstable splint

old bac the tube bandage , proxim all and distall , and trim

ig 4 The ste p b ste p proce dure , including graphics and instructions

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Ove rvie w of cast, splint, orthosis, and bandage te chni ue s—dem onstration format and icons

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On ce th e procedu re is f n ish ed, a f n al assessm en t section is provided to su m m arize th e m ain requ irem en ts o th e cast, splin t, orth osis, or su pport ban dage in order to sh ow th e expected ran ge o m otion an d to avoid com plication s ( ig 4 ). Typically, th e im ages or th e f n al assessm en t in dicate w h at th e im m obilization ban dage sh ou ld look like, bu t m ay also in clu de im ages o th e in side o th e cast, a ter it h as been rem oved, to in dicate its orm or sh ape rom th e in side, or to sh ow oth er eatu res th at cou ld n ot be seen i it w as still on th e patien t.

Su m m a r

• A ran ge o in stru ction s, illu stration s, an d pictograph s h ave been developed an d in clu ded in to th e 55 dem on stration videos (an d ch apters 15–18) or en h an ced learn in g • Fu rth er in orm ation on m an y o th e gen eral tech n iqu es u sed in th e dem on stration s can be ou n d in ch apter 14.1 Overview o cast, splin t, orth osis, an d ban dage tech n iqu es, an d in oth er earlier ch apters o th e book.

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Ca s t s p lit t in g , ca s t re m o va l

Occasion ally, special addition al in stru ction s are provided, su ch as cast rem oval, w h ere special atten tion m u st be paid w h en rem ovin g th e cast to avoid bon y prom in en ces etc. Th is is particu larly so w h en th e oscillatin g cast saw is u sed. In dem on stration s or rem ovable casts an d orth oses, addition al in orm ation is also provided on h ow to rem ove th e cast, trim th e excess m aterial, an d attach relevan t f xin g m aterials su ch as velcro, so th at th e cast can be easily reapplied by th e doctor or patien t.

IN

SS SS

NT

Me tacarpal he ads re m ain fre e to allow fre e m otion of the nge rs

The splint should e xte nd to the top of the bice ps, and the inside of the e lbow re m ains fre e

ig 4 inal asse ssm e nt In the above e xam ple , the nal la e r of bandage s has be e n re m ove d to m ore e ffe ctive l show the form and e xte nt of the splint

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Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

TEC NI pper extremit

ES

pper extremit

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o n g a rm s p lin t u s in g p la s t e r o f Pa ris

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o n g a rm s p lin t u s in g s n t e t ic

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o n g a rm ca s t u s in g p la s t e r o f Pa ris

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o n g a rm ca s t u s in g s n t e t ic , co m ica s t t e c n i u e

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Sa rm ie n t o

u m e ra l ra ce u s in g s n t e t ic, co m ica s t t e c n i u e

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o rs o p a lm a r ra d ia l s o r t a rm s p lin t u s in g p la s t e r o f Pa ris

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o rs o p a lm a r ra d ia l s o r t a rm s p lin t u s in g s n t e t ic

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Pa lm a r s o r t a rm s p lin t u s in g p la s t e r o f Pa ris

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Pa lm a r s o r t a rm s p lin t u s in g s n t e t ic

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o rs a l s o r t a rm s p lin t u s in g s n t e t ic

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S o r t a rm ca s t u s in g p la s t e r o f Pa ris

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S o r t a rm ca s t u s in g s n t e t ic, co m ica s t t e c n i u e

3 3

5 3

T um

s p ica s p lin t u s in g p la s t e r o f Pa ris

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5 4

T um

s p ica s p lin t u s in g s n t e t ic

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5 5

S o r t a rm ca s t u s in g p la s t e r o f Pa ris

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S o r t a rm s ca p o id ca s t u s in g s n t e t ic , co m ica s t t e c n i u e

3

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o rs o p a lm a r u ln a r gu t t e r s o r t a rm s p lin t in clu d in g t o o r m o re fin ge rs u s in g p la s t e r o f Pa ris

4 5

o rs o p a lm a r u ln a r gu t t e r s o r t a rm s p lin t in clu d in g t o o r m o re fin ge rs u s in g s n t e t ic

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Pa lm a r s o r t a rm s p lin t in clu d in g t e fin ge rs u s in g p la s t e r o f Pa ris

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S o r t a rm ca s t in clu d in g t o o r m o re fin ge rs u s in g s n t e t ic , co m ica s t t e c n i u e

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le in e r t d n a m ic s p lin t u s in g p la s t e r o f Pa ris

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5

le in e r t d n a m ic s p lin t u s in g s n t e t ic , co m ica s t t e c n i u e

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5

5

e m o va le fin ge r s p lin t u s in g s n t e t ic

5

6

t ra ct io n a n d re d u ct io n

o r t o s is u s in g s n t e t ic

a lle t fin ge r s p lin t u s in g s n t e t ic

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IN IC TI N

• ractu re of th e • ractu re of th e • ractu re of th e • ractu re of th e • Epicon dylitis

forearm radial h ead distal h u m eru s epicon dyle

• Stabilization of th e forearm an d elbow

IP

NT

Cast padding Plaste r of Paris splint or cm 3 Tube bandage

cm,

cm,

cm in dispe nse r box

4 Cre pe pape r bandage 5 Elastic bandage 6

au e bandage Cut tube bandage Scissors Surgical tape or bandage clips

P

S NN

1 3

ppe r e xtre mit

P SITI NIN

e

n

i

e

5

ong arm splint using plaste r of Paris

Se at the patie nt com fortabl on a stool Place the affe cte d lim b on the table , in a functional position, with e xion of the e lbow

SP CI

T IN S T

P IN

IN

• Th e distal palm ar crease sh ou ld rem ain free • rotection of th e lateral an d m edial epicon dyle • rotection of th e olecran on • h ile th e splin t is settin g th e lim b sh ou ld be position ed h alfw ay betw een su pin ation an d pron ation

3

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

5

C

Cut hole s in the tube bandage for the thum b

Appl the padding ma e a hole for the thum b

rap the fore arm using the half ove rlapping te chni ue

The padding prote cts the bon promine nce s

Appl the pape r bandage to form a barrie r be twe e n the dr padding and the we t POP

n

Pull the tube bandage tight to re m ove an wrin le s

e

Appl the tube bandage up to the shoulde r

i

e

P

a lf ove rla p p in g

rap the fore arm using the half ove rlapping te chni ue

old the POP splint in two to m a e e ight la e rs

old up the splint be fore subm e rging in wate r

3

ppe r e xtre mit

5

ong arm splint using plaste r of Paris

Ove rlap the cut se ction of the splint

Trim the splint at the le ve l of the MCP oints

e inforce the are a of the e lbow with a short POP splint

Appl a we t gau e bandage to hold the splint in place

rap the fore arm using the half ove rlapping te chni ue

se the gure of e ight te chni ue at the e lbow to avoid an e xce ssive am ount of la e rs

Mold the splint and support the arm until it is se t

Afte r the splint has se t, fold bac the tube bandage proxim all and distall

Pass the thum b through the hole in the tube bandage

Position the splint and cut at the e lbow to allow ove rlapping

e

n

i

e

Submerge the splint in water for a few seconds, remove, and s uee e out excess water

Stretch and smooth out the splint, pressing the la ers together, resulting in a compact splint If this procedure is not done, puff pastr plaster will result, causing an unstable splint

3

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

5

C

Cut through all la e rs, be ginning distall

Com ple te the cutting proxim all

Appl an e lastic bandage to hold the splint in place , using the half ove rlapping te chni ue

se the gure of e ight te chni ue at the e lbow to avoid an e xce ssive am ount of la e rs

Se cure the bandage with surgical tape or bandage clips

e

n

Mar the splitting line

i

e

P

IN

SS SS

NT

Me tacarpal he ads re main fre e to allow fre e Tube bandage m otion of the nge rs

The should e xte nd to the top of the Tubesplint bandage bice ps, and the inside of the e lbow re mains fre e

Tube bandage

3

ppe r e xtre mit

e

n

i

e

5

ong arm splint using plaste r of Paris

3

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

5

ong arm splint using s nthetic

IN IC TI N

• ractu re of th e • ractu re of th e • ractu re of th e • ractu re of th e • Epicon dylitis

forearm radial h ead distal h u m eru s epicon dyle

• Stabilization of th e forearm an d elbow

IP

NT

igid s nthe tic splint

cm x

cm

Cut tube bandage 3 Tube bandage

cm in dispe nse r box

4 Elastic bandage 5

au e bandage

6 Cast padding Scissors love s Surgical tape or bandage clips

P

S NN

1 3 3

ppe r e xtre mit

P SITI NIN

e

n

i

e

5

ong arm splint using s nthe tic

Se at the patie nt com fortabl on a stool Place the affe cte d lim b on the table , in a functional position, with e xion of the e lbow

SP CI

T IN S T

P IN

IN

• Th e distal palm ar crease sh ou ld rem ain free • rotection of th e lateral an d m edial epicon dyle • rotection of th e olecran on • h ile th e splin t is settin g th e lim b sh ou ld be position ed h alfw ay betw een su pin ation an d pron ation

3 4

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

5

C

Cut hole s in the tube bandage for the thum b

Appl the padding ma e a hole for the thum b rst

rap the fore arm using the half ove rlapping te chni ue

se the gure of e ight te chni ue at the elbow to avoid an e xce ssive amount of la ers

In orde r to t the diam e te r of the arm , the splint la e rs m ust be fanne d out proxim all

Subm e rge the splint in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Appl the splint le ave the inside of the e lbow fre e

n

Pull the tube bandage tight to re m ove an wrin le s

e

Appl the tube bandage up to the shoulde r

i

e

P

a lf ove rla p p in g

3 5

ppe r e xtre mit

e

5

ong arm splint using s nthe tic

rap the splint with a gau e bandage , using the half ove rlapping te chni ue

e

n

i

Trim the splint along the MCP oints

3 6

Mold the splint to the arm

Trim the splint proxim all and wrap with a gau e bandage

old bac the tube bandage , proxim all and distall

Pass the thum b through the hole in the tube bandage

old the splint in the re uire d position until se t

Cut the splint ope n, e ithe r on the inne r side , or as shown he re on the oute r side

Appl an e lastic bandage to hold the splint in place , using the half ove rlapping te chni ue

se the gure of e ight te chni ue at the e lbow to avoid an e xce ssive am ount of la e rs

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

e

5

Klaus Dre sing, os Engele n

e

n

i

Se cure the bandage with surgical tape or bandage clips

IN

SS SS

NT

Me tacarpal he ads re main fre e to allow fre e m otion of the nge rs

The ole cranon re m ains fre e of splint

Caption The splint should e xte nd to the top of the bice ps

Caption The splint is form e d to the shape of the wrist and the uppe r arm

Caption

3

ppe r e xtre mit

e

n

i

e

5

ong arm splint using s nthe tic

3

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

5

3

ong arm cast using plaster of Paris

IN IC TI N

• ractu re of th e radiu s • ractu re of th e u ln a • ractu re of th e elbow • Epicon dylitis

• Stabilization of th e forearm an d elbow

IP

NT

Plaste r of Paris rolls Plaste r of Paris splint 3 Tube bandage

cm or cm or

cm cm

cm in dispe nse r box

4 Cre pe pape r bandage 5 Cast padding 6 Cut tube bandage Scissors Oscillating saw Cast spre ade r Surgical tape or bandage clips Elastic bandage

P

S NN

1 3

ppe r e xtre mit

P SITI NIN

e

n

i

e

5

3

ong arm cast using plaste r of Paris

Se at the patie nt com fortabl on a stool Place the affe cte d lim b on the table , in a functional position, with e xion of the e lbow

SP CI

T IN S T

P IN

IN

• Th e distal palm ar crease sh ou ld rem ain free • rotection of th e lateral an d m edial epicon dyle • rotection of th e olecran on • h ile th e splin t is settin g th e lim b sh ou ld be position ed h alfw ay betw een su pin ation an d pron ation • If n ecessary th e cast can be split after settin g

3

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

5

C

The patie nt m a e s a st to allow the tube bandage to be trim m e d, which e nsure s fre e m ove m e nt of the nge rs

Appl the padding ma e a hole for the thum b rst

Ma e a te ar in the padding to e nsure sm ooth prote ction be twe e n the thum b and inde x nge r

n

Cut a hole in the tube bandage for the thum b

e

Appl the tube bandage up to the shoulde r Pull the tube bandage tight to re m ove an wrin le s

i

e

P

3

Klaus Dre sing, os Engele n

a lf ove rla p p in g

rap the fore arm using the half ove rlapping te chni ue

Appl the pape r bandage to form a barrie r be twe e n the dr padding and the we t POP

se the gure of e ight te chni ue at the e lbow to avoid an e xce ssive am ount of la e rs

Cut halfwa through the bandage , from proxim al to distal, for e as application be twe e n the thum b and the inde x nge r

rap the fore arm using the half ove rlapping te chni ue

3

ppe r e xtre mit

e

n

i

e

5

3

ong arm cast using plaste r of Paris

3

Subm e rge the roll of POP in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Cut halfwa through, from proxim al to distal, for e as application be twe e n the thum b and the inde x nge r

rap the arm using the half ove rlapping te chni ue

Stre tch and smooth out the splint, pre ssing the la ers toge the r, re sulting in a compact splint If this proce dure is not done, puff pastr plaster will re sult, causing an unstable splint

Appl a la e r POP splint on the dorsal side for e xtra stabilit

Subm e rge the splint in wate r for a fe w se conds, re m ove , and s ue e e out the e xce ss wate r

Position the splint and cut at the e lbow to allow ove rlapping

Sm ooth out the splint

old bac the tube bandage , proxim all and distall , and trim

Appl the nal rolls of POP

Mold the cast to the de sire d position of the wrist and e lbow

Ensure the re is fre e m ove m e nt of the shoulde r, nge rs, and thum b

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Split the cast with the oscillating saw

inish the splitting b cutting the padding and tube bandage com ple te l with scissors

Appl an e lastic bandage to se cure the split cast rap the arm using the half ove rlapping te chni ue

n

The saw blade oscillate s and doe s not rotate , so the re is no dire ct harm to the s in

e

Mar the splitting line

i

e

5

3

Klaus Dre sing, os Engele n

ide n the split with the cast spre ade r

Se cure the bandage with surgical tape or bandage clips

3 3

ppe r e xtre mit

IN

SS SS

NT

re e e xion of the nge rs and thum b at the MCP oints

The re is two nge r s bre adth be twe e n the cast and the arm pit

e

n

i

e

5

3

ong arm cast using plaste r of Paris

3 4

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

5

4

ong arm cast using s nthetic, combicast techni ue

IN IC TI N

• ractu re of th e radiu s • ractu re of th e u ln a • ractu re of th e elbow • Epicon dylitis

• Stabilization of th e forearm an d elbow

IP

NT

igid s nthe tic splint

cm x

Se mirigid casting tape

cm

cm

3 Cut tube bandage s 4 Tube bandage 5 Tube bandage

cm in dispe nse r box cm in dispe nse r box

6 Elastic foam tape Scissors love s Elastic bandage

P

S NN

1 3 5

ppe r e xtre mit

P SITI NIN

e

n

i

e

5

4

ong arm cast using s nthe tic, combicast te chni ue

Se at the patie nt com fortabl on a stool Place the affe cte d lim b on the table , in a functional position, with e xion of the e lbow

SP CI

T IN S T

P IN

IN

• Th e distal palm ar crease sh ou ld rem ain free • rotection of th e lateral an d m edial epicon dyle • rotection of th e olecran on • h ile th e splin t is settin g th e lim b sh ou ld be position ed h alfw ay betw een su pin ation an d pron ation • If n ecessary th e cast can be split after settin g

3 6

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

5

C

Appl the padding ove r the radial and ulnar st loid proce sse s, the radial and ulnar e picond le s, and the ole cranon

The patie nt m a e s a st to allow the tube bandage to be trim m e d, which e nsure s fre e m ove m e nt of the nge rs

Appl a small tube bandage ove r the thum b

Appl padding ove r the bon promine nce s using e lastic foam tape

Appl the semirigid casting tape cut halfwa through, proximal to distal, for eas application between the thumb and the inde x nger

rap the fore arm using the half ove rlapping te chni ue

se the gure of e ight te chni ue at the e lbow to avoid an e xce ssive am ount of la e rs

old bac the tube bandage , proxim all and distall

n

Cut a hole in the tube bandage for the thum b

e

Appl the tube bandage up to the shoulde r Pull the tube bandage tight to re m ove an wrin le s

i

e

P

4

Klaus Dre sing, os Engele n

a lf ove rla p p in g

3

ppe r e xtre mit

Trim the rigid splint at an angle , distall and proxim all

Ensure the splint e nds cm short of the se m irigid cast, distall and proximall The patie nt holds the splint in place proximall

The splint has a trape oid form

Subm e rge the se m irigid casting tape in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Cut halfwa through the semirigid casting tape, from proximal to distal, for eas application between the thumb and the inde x nger

rap the fore arm using the half ove rlapping te chni ue

Subm e rge the e lastic bandage in wate r using a we t bandage acce le rate s the se tting

Mold the cast and hold it in e xion at the e lbow and in functional position at the wrist until it is se t

e m ove the we t bandage afte r the cast has se t

e

n

i

e

5

4

ong arm cast using s nthe tic, combicast te chni ue

IN

SS SS

NT

Caption

re e e xion of the nge rs and thum b at the MCP oints

3

The re is two nge r s bre adth be twe e n the cast and the arm pit

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

4

Klaus Dre sing, os Engele n

e

5

C ST

e m ove the cast b ope ning the com bicast

i

Split all la e rs, including the padding and the tube bandage

n

e fore splitting the cast, pre ss on both side s of the hand to cre ate a sm all space for the scissors

e

Mar the splitting line

The re is e xion at the e lbow and functional position of the wrist

3

ppe r e xtre mit

e

n

i

e

5

4

ong arm cast using s nthe tic, combicast te chni ue

33

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

5

5

Sarmiento humeral brace using s nthetic, combicast techni ue

IN IC TI N

• •

iaph yseal fractu res of th e h u m eru s ot recom m en ded for prim ary fractu re care

• Stabilization of th e h u m eral sh aft

IP

NT

igid s nthe tic splint Se mirigid casting tape 3 Se mirigid casting tape 4 Tube bandage 5 Tube bandage

cm x

cm

cm cm

cm in dispe nse r box cm in dispe nse r box

6 Cut tube bandage s e lcro strips loop adhe sive e lcro strips hoo

nonadhe sive

Scissors love s Elastic bandage

P

S NN

surge on if ne e de d

33

ppe r e xtre mit

P SITI NIN

e

n

i

e

5

5

Sarmie nto humeral brace using s nthe tic, combicast te chni ue

Se at the patie nt com fortabl on a stool The affe cte d lim b hangs in the air, with

e xion of the e lbow

SP CI

T IN S T

P IN

IN

• Skin irritation u n der th e axilla • ircu lation

33

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

5

C

Appl the tube bandage and tie around the ne c

Pull the tube bandage tight to re m ove an wrin le s

An assistant is ne e de d to hold the shoulde r and e lbow in position for the re st of the proce dure

Thre ad a smalle r double le ngth tube bandage unde r the rst it will be use d late r to m a e splitting the brace e asie r

n

The se slits allow application around the ne c

e

Cut two slits in the tube bandage , one long and one short

i

e

P

5

Klaus Dre sing, os Engele n

Appl the rst la e r of se m irigid casting tape the assistant holds the tape at the shoulde r

rap the se m irigid casting tape twice from e lbow to shoulde r, longitudinall

rap the se m irigid casting tape ove r the ole cranon to hold the e lbow at e xion

rap the re st of the uppe r arm using the half ove rlapping te chni ue

333

ppe r e xtre mit

a lf ove rla p p in g

Ensure the re are no cre ase s in the tube bandage at the inside of the e lbow

Appl the rigid splint and trim to the re uire d le ngth

Appl thre e strips of adhe sive ve lcro with loops

Subm e rge the e lastic bandage in wate r using a we t bandage acce le rate s the se tting

e m ove the we t bandage afte r the brace has se t

Mar the brace whe re it ne e ds to be trimm e d

Mar the e picond le s and the fold of the e lbow

Ensure the ole cranon fossa is fre e

e

n

i

e

5

5

Sarmie nto humeral brace using s nthe tic, combicast te chni ue

old the sm all tube bandage bac ove r the se m irigid casting tape , and hold in place with the ne xt la e r of se m irigid casting tape

Ensure the re is e nough space at the arm pit and shoulde r

334

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Proxim all , slide one blade of the scissors into the oute r tube bandage

uide the scissors down the tube bandage and split ope n the oute r la e r of se m irigid casting tape

Cut through the tube bandage distall

e m ove the oute r se ction of the small tube bandage

Ensure the split se ction of se mirigid casting tape can be ope ne d

Cut the large tube bandage from around the ne c

Position the lowe r tube bandage at the oute r side of the ap

Ope n the ap, and guide the scissors along the sm all tube bandage to cut through the lowe r la e r of se m irigid casting tape

Cut through the large tube bandage

Ope n the brace and re m ove it

n

Cut through the small tube bandage proxim all

e

Split the se mirigid casting tape using the sm all tube bandage as a guide

i

e

5

5

Klaus Dre sing, os Engele n

335

ppe r e xtre mit

Trim the brace to the de sire d shape

Pre pare a ne w tube bandage and place ove r the arm be fore appl ing the brace

The ove rlapping se ctions pre ve nt the s in be ing trappe d be twe e n the e dge s

Attach the ve lcro strips with hoo s com pre ss the brace slightl and close provisionall with the strips

Appl te nsion to the tube bandage , loose n the ve lcro strips, place the brace in the nal position and re faste n the strips

Ensure fre e e xion and e xte nsion of the e lbow

Ensure fre e m ove m e nt of the ole cranon fossa

old the tube bandage ove r the brace to provide prote ction

e

n

i

e

5

5

Sarmie nto humeral brace using s nthe tic, combicast te chni ue

IN

SS SS

NT

Che c that the brace is not too tight b ta ing the pulse Che c the re is no s in irritation

336

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

5

6

Dorsopalmar radial short arm splint using plaster of Paris

IN IC TI N

•

ractu re of th e distal radiu s

• Stabilization of th e dorsal forearm an d w rist

IP

NT

Plaste r of Paris splint or cm

cm,

cm,

Cast padding 3 Tube bandage

cm in dispe nse r box

4 Cre pe pape r bandage 5 Elastic bandage 6

au e bandage Cut tube bandage Scissors Surgical tape or bandage clips Elastic bandage

P

S NN

surge on in case of re duction

33

ppe r e xtre mit

P SITI NIN

e

n

i

e

5

6

Dorsopalmar radial short arm splint using plaste r of Paris

Se at the patie nt com fortabl on a stool Place the affe cte d lim b on the table , in a functional position

SP CI

T IN S T

P IN

IN

• Th e distal palm ar crease sh ou ld rem ain free • Th e m etacarpal h eads sh ou ld rem ain free • ree exion of th e elbow sh ou ld be possible • h ile th e splin t is settin g th e lim b sh ou ld be position ed h alfw ay betw een su pin ation an d pron ation

33

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

5

C

e

P

6

Klaus Dre sing, os Engele n

Position the wrist in ulnar abduction

Appl the tube bandage

Cut an ope ning for the thum b

Cut a se cond ope ning ove r the PIP oint of the inde x nge r, to allow the tube bandage to be folde d bac ove r the thum b late r

Ensure the wrist is in slight ulnar de viation

Appl the padding m a e a hole for the thum b rst

Ma e a te ar in the padding to e nsure sm ooth prote ction be twe e n the thum b and inde x nge r

rap the fore arm using the half ove rlapping te chni ue

Appl the pape r bandage to form a barrie r be twe e n the dr padding and the we t POP

rap the fore arm using the half ove rlapping te chni ue

i

dorsal e xion

e

n

Place the wrist in

dorsal e xion and

a lf ove rla p p in g

33

ppe r e xtre mit

old the POP splint to the appropriate le ngth and trim to the re uire d shape

Starting two nge r s bre adth from the e lbow cre ase , m e asure a scissor s le ngth, and cut the splint to this point

Shape the splint li e this

Subm e rge the splint in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Appl the splint and m old into place

Trim the splint at the palm ar cre ase to e nsure fre e e xion of the nge rs, use the thum b as a re fe re nce

Trim the splint dorsall at the MCP oints to e nsure fre e e xte nsion

Appl the gau e bandage using the half ove rlapping te chni ue

old bac the tube bandage , proxim all and distall

Pass the thum b through the hole in the tube bandage

Place the thum b into the de sire d position and hold in place until the splint is se t

se the at hand te chni ue to hold the splint in the corre ct position

e

n

i

e

5

6

Dorsopalmar radial short arm splint using plaste r of Paris

34

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

e

5

6

Klaus Dre sing, os Engele n

n

i

Cut the gau e bandage and padding starting distall

e

Split the splint com ple te l at the ulnar side se the ste p b ste p splitting and xing te chni ue to avoid loss of re duction

Cut the tube bandage proxim all

Appl an e lastic bandage proximall to close the splint

Cut the re st of the tube bandage and close the splint using this te chni ue avoids loss of re duction

Se cure the bandage with surgical tape or bandage clips

Cut anothe r se ction of the tube bandage and close the splint

34

ppe r e xtre mit

PIN C

SS SS

NT

re e e xion of the nge rs at the MCP oints

The splint should e nd two nge r s bre adth from the e lbow cre ase to allow fre e e xion of the e lbow

re e m ove m e nt of the MCP oints

The s e le ton illustrate s the line of the MCP oints

e

n

i

e

5

6

Dorsopalmar radial short arm splint using plaste r of Paris

rist is in

34

re e m ove m e nt of the thum b and fre e palm ar cre ase

re e m ove m e nt of the thum b

dorsal e xion

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

5

Dorsopalmar radial short arm splint using s nthetic

IN IC TI N

•

ractu re of th e distal radiu s

• Stabilization of th e dorsal forearm an d w rist

IP

NT

igid s nthe tic splint

cm or

cm

Cut tube bandage 3 Tube bandage

cm in dispe nse r box

4 Cast padding 5

au e bandage

6 Elastic bandage Scissors love s Surgical tape or bandage clips

P

S NN

surge on in case of re duction

343

ppe r e xtre mit

P SITI NIN

e

n

i

e

5

Dorsopalmar radial short arm splint using s nthe tic

Se at the patie nt com fortabl on a stool Place the affe cte d lim b on the table , in a functional position

SP CI

T IN S T

P IN

IN

• Th e distal palm ar crease sh ou ld rem ain free • Th e m etacarpal h eads sh ou ld rem ain free • ree exion of th e elbow sh ou ld be possible • h ile th e splin t is settin g th e lim b sh ou ld be position ed h alfw ay betw een su pin ation an d pron ation

344

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

5

C

Position the wrist in ulnar abduction

De m onstration of

The axis of the thum b is in line with the radius

n

Pull the tube bandage tight to re m ove an wrin le s

e

Appl the tube bandage cut an ope ning for the thum b

i

e

P

lnar abduction is de m onstrate d

Position the fore arm midwa be twe e n s upination and pronation

Ensure the wrist is in slight ulnar de viation

dorsal e xion

dorsal e xion and

Ma e a hole in the padding for the thum b

a lf o ve rla p p in g

Ma e a te ar in the padding to e nsure sm ooth prote ction be twe e n the thum b and inde x nge r

Appl the padding using the half ove rlapping te chni ue

345

ppe r e xtre mit

orde r of padding and splint at the m e tacarpal he ads

Me asure the splint to the appropriate le ngth ne e de d

In orde r to t the diam e te r of the fore arm , the splint la e rs m ust be fanne d out proxim all and the e nds trim m e d

Place the splint two nge r s bre adth be low the e lbow cre ase and trim along the MCP oints

Ensure the m e tacarpal he ads re m ain fre e

Trim the splint to the de sire d shape

Shape the splint li e this to give a small palmar and a large dorsal com pone nt

Subm e rge the splint in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Appl the splint dorsall and m old into place

Subm e rge the gau e bandage in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

rap the gau e bandage around the splint, be ginning at the wrist

Ensure the palm ar com pone nt of the splint is on the palm ar side

e

n

i

e

5

Dorsopalmar radial short arm splint using s nthe tic

346

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Place the thum b in the re uire d position, and m old the splint in corre ct dorsal e xion and ulnar abduction while it se ts

old bac the tube bandage , distall and proxim all

Split the splint on the ulnar aspe ct afte r it has se t

se the ste p b ste p splitting and xing te chni ue to split the splint, and close it with an e lastic bandage to avoid loss of re duction

rap the fore arm using the half ove rlapping te chni ue

Se cure the bandage with surgical tape or bandage clips

n

e m ove glove s for e asie r m olding of the splint

e

rap the fore arm using the half ove rlapping te chni ue

i

e

5

Klaus Dre sing, os Engele n

34

ppe r e xtre mit

PIN C

SS SS

NT

The le ngth of the splint allows fre e e xion of the e lbow

The splint should e nd two nge r s bre adth from the e lbow cre ase

Ensure fre e m ove m e nt of the nge rs and thum b

Me tacarpal he ads should re m ain fre e

The distal palm ar cre ase is fre e to allow full m otion of the nge rs

Shar de sign of the splint in late ral vie w Exact contouring of the dorsal and radial aspe cts of the wrist oint can be se e n

The dorsal e xte nsion and the space for the base of the thum b are cle arl visible

The MCP oints are fre e dorsall , and the splint wraps far e nough around on the ulnar side to give support

re e m ove m e nt of the thum b is possible The splint provide s support for the distal radius

e

n

i

e

5

Dorsopalmar radial short arm splint using s nthe tic

Corre ct position of the splint on the radial aspe ct

34

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

5

Palmar short arm splint using plaster of Paris

IN IC TI N

• Stable n on displaced fractu res of th e distal radiu s • adial n er e palsy

• Stabilization of th e distal forearm an d w rist

IP

NT

Cast padding Plaste r of Paris splint or cm 3 Tube bandage 4 Tube bandage

cm,

cm,

cm in dispe nse r box cm in dispe nse r box

5 Cre pe pape r bandage 6 Scissors Elastic bandage au e bandage Cut tube bandage s Surgical tape or bandage clips

P

S NN

1 34

ppe r e xtre mit

P SITI NIN

e

n

i

e

5

Palmar short arm splint using plaster of Paris

Se at the patie nt com fortabl on a stool Place the affe cte d lim b on the table in supination during application, and in a functional position during se tting

SP CI

T IN S T

P IN

IN

• Th e splin t exten ds distally to th e distal palm ar crease an d th e m etacarpal h eads • Th e distal palm ar crease sh ou ld rem ain free • etacarpal h eads sh ou ld rem ain free • ree exion of th e elbow sh ou ld be possible • h ile th e splin t is settin g th e lim b sh ou ld be position ed h alfw ay betw een su pin ation an d pron ation

35

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

5

C

Cut an ope ning for the thum b

Appl a sm all tube bandage ove r the thum b

Appl both tube bandage s sm oothl and fre e of wrin le s

Appl the padding ma e an ope ning for the thum b rst

Ma e a te ar in the padding to e nsure sm ooth prote ction be twe e n the thum b and inde x nge r

e

n

Appl the tube bandage and pull it tight to avoid wrin le s

i

e

P

a lf ove rla p p in g

rap the fore arm using the half ove rlapping te chni ue

orde r of padding and splint at the m e tacarpal he ads

Ensure the wrist is in slight ulnar de viation

Appl the pape r bandage m a e a te ar to accomm odate the thum b se the pape r bandage to form a barrie r be twe e n the dr padding and the we t POP

dorsal e xion and

rap the fore arm using the half ove rlapping te chni ue

35

ppe r e xtre mit

e

n

i

e

5

Palmar short arm splint using plaster of Paris

old the splint in two to m a e an la e r splint, and trim to the de sire d shape proxim all

Place the splint two nge r s bre adth from the e lbow cre ase , and trim to the de sire d le ngth distall , le aving the MCP oints fre e

Subm e rge the splint in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Stretch and smooth out the splint, pressing the la ers together, resulting in a compact splint If this proce dure is not done, puff pastr plaster will result, causing an unstable splint

Shape the splint to pass be twe e n the thum b and the inde x nge r

old bac the tube bandage ove r the splint, proxim all and distall

35

Shape the splint li e this

Appl the gau e bandage to hold the splint in position

Shape the splint li e this

Appl the splint and m old into place

Mold the splint to the hand and fore arm

rap the fore arm using the half ove rlapping te chni ue

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

e

5

Klaus Dre sing, os Engele n

i

se the ste p b ste p splitting and xing te chni ue to split the splint, and close it with an e lastic bandage to avoid loss of re duction

n

Ensure the re is a slight ulnar de viation

e

Mold the splint into the de sire d shape and hold in position until se t Ensure there is dorsal e xion of the wrist

Se cure the bandage with surgical tape or bandage clips

353

ppe r e xtre mit

IN

SS SS

NT

Me tacarpal he ads re m ain fre e

re e e xion and e xte nsion of the nge rs and thum b

The splint should e nd two nge r s bre adth from the e lbow cre ase to allow fre e m otion of the e lbow

The nal shape and contours of the splint show it is m olde d to the fore arm and hand

The ap be twe e n the thum b and inde x nge r is visible

Distal palm ar cre ase is fre e and the patie nt is able to m a e a st

The gutte r form of the splint supports the ulna distall

On the palm ar side of the wrist, the carpus and the m e tacarpus are supporte d

e

n

i

e

5

Palmar short arm splint using plaster of Paris

354

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

5

Palmar short arm splint using s nthetic

IN IC TI N

• Stable n on displaced fractu res of th e distal radiu s • adial n er e palsy

• Stabilization of th e distal forearm an d w rist

IP

NT

igid s nthe tic splint Cut tube bandage 3

Tube bandage

4

Cast padding

5

au e bandage

6

Elastic bandage

cm or

cm

cm

cm in dispe nse r box

Scissors love s Surgical tape or bandage clips

P

S NN

1 355

ppe r e xtre mit

P SITI NIN

e

n

i

e

5

Palmar short arm splint using s nthe tic

Se at the patie nt com fortabl on a stool Place the affe cte d lim b on the table in supination during application, and in a functional position during se tting

SP CI

T IN S T

P IN

IN

• Th e splin t exten ds distally to th e distal palm ar crease an d th e m etacarpal h eads • Th e distal palm ar crease sh ou ld rem ain free • etacarpal h eads sh ou ld rem ain free • ree exion of th e elbow sh ou ld be possible • h ile th e splin t is settin g th e lim b sh ou ld be position ed h alfw ay betw een su pin ation an d pron ation

356

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

5

C

Cut a se cond ope ning ove r the PIP oint of the inde x nge r, to allow the tube bandage to be folde d bac ove r the thum b late r

Appl a sm all tube bandage ove r the thum b Appl both tube bandage s sm oothl and without wrin le s

Appl the padding ma e an ope ning for the thum b rst

rap the fore arm using the half ove rlapping te chni ue

Ensure the wrist is in slight ulnar deviation

orde r of padding and splint at the m e tacarpal he ads

n

Cut an ope ning for the thum b

e

Appl the tube bandage

i

e

P

a lf ove rla p p in g

In order to t the diame te r of the forearm, the splint la ers must be fanne d out proximall trim the splint to the de sire d shape

Shape the splint li e this

dorsal e xion and

Subm e rge the splint in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

35

ppe r e xtre mit

Appl the splint, and trim it two nge r s bre adth be low the e lbow cre ase

Trim the splint at the distal palm ar cre ase

Position the splint ap be twe e n the thum b and inde x nge r

Appl the gau e bandage to hold the splint in position

rap the fore arm using the half ove rlapping te chni ue

Mold the splint into the de sire d shape , with the patie nt s nge rs spre ad, and hold in position until se t

old bac the tube bandage with the se cond ope ning pulle d ove r the thum b

Split the splint com ple te l ope n, and hold in place with an e lastic bandage

rap the fore arm using the half ove rlapping te chni ue

Se cure the bandage with surgical tape or bandage clips

e

n

i

e

5

Palmar short arm splint using s nthe tic

35

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

NT

5

SS SS

The contours of the hand are cle arl visible

The splint should e nd two nge r s bre adth from the e lbow cre ase to allow fre e e xion of the e lbow

On the palm ar side of the wrist, the carpus and the m e tacarpus are supporte d

The distal palmar cre ase is fre e and the patie nt is able to m a e a st

The gutte r form of the splint supports the distal fore arm and wrist

The ap be twe e n the thum b and the inde x nge r is visible

n

re e e xion and e xte nsion of the nge rs and thum b

e

Me tacarpal he ads re main fre e

i

e

IN

35

ppe r e xtre mit

e

n

i

e

5

Palmar short arm splint using s nthe tic

36

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

5

Dorsal short arm splint using s nthetic

IN IC TI N

• Stable n on displaced fractu res of th e distal radiu s

• Stabilization of th e distal forearm an d w rist

IP

NT

igid s nthe tic splint Cut tube bandage 3

Tube bandage

4

Cast padding

5

au e bandage

6

Elastic bandage

cm or

cm

cm

cm in dispe nse r box

Scissors love s Surgical tape or bandage clips

P

S NN

surge on in case of re duction

36

ppe r e xtre mit Dorsal short arm splint using s nthe tic

e

n

i

e

5

P SITI NIN

Se at the patie nt com fortabl on a stool Place the affe cte d lim b on the table , in a functional position

SP CI

T IN S T

P IN

IN

• Th e splin t exten ds distally to th e m etacarpal h eads • Th e distal palm ar crease sh ou ld rem ain free • etacarpal h eads sh ou ld rem ain free • ree exion of th e elbow sh ou ld be possible

36

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

C

e

5

P

i

Appl the padding m a e an ope ning for the thum b rst

n

Cut an ope ning for the thum b

e

Appl the tube bandage sm oothl without wrin le s

a lf o ve rla p p in g

Ma e a te ar in the padding to e nsure sm ooth prote ction be twe e n the thum b and inde x nge r

Ensure the m e tacarpal he ads re main fre e

Trim the splint to le ave the MCP oints fre e

rap the fore arm using the half ove rlapping te chni ue

In orde r to t the diam e te r of the fore arm , the Trim the splint to the de sire d shape splint la e rs m ust be fanne d out proximall

Cut a sm all se ction from the splint to allow fre e m ove m e nt of the thum b

Shape the splint li e this

363

ppe r e xtre mit

e

n

i

e

5

Dorsal short arm splint using s nthe tic

364

Subm e rge the splint in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Appl the splint and m old into place

Appl the gau e bandage to hold the splint in place , using the half ove rlapping te chni ue

Place the wrist in dorsal e xion using the at hand te chni ue

old bac the tube bandage , proximall and distall

Mold the splint to the de sire d shape and hold in position until se t

Ensure that the m e tacarpals are not com pre sse d while m olding the splint

se the ste p b ste p splitting and xing te chni ue to split the splint, and close it with an e lastic bandage , to avoid loss of re duction

Se cure the bandage with surgical tape or bandage clips

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

SS SS

NT

The splint should e nd two nge r s bre adth from the e lbow cre ase to allow fre e e xion of the e lbow

The splint has a gutte r form that supports the distal fore arm and a ap be twe e n the thum b and the inde x nge r

The splint has an obli ue e dge at the m e tacarpal he ads

n

re e e xion and e xte nsion of the nge rs and thum b

e

The m e tacarpal he ads re m ain fre e

i

e

5

PIN C

Proxim all , the rounde d e dge allows fre e m ove m e nt of the e lbow

365

ppe r e xtre mit

e

n

i

e

5

Dorsal short arm splint using s nthe tic

366

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

5

Short arm cast using plaster of Paris

IN IC TI N

•

ractu re of th e distal radiu s

• Stabilization of th e distal forearm an d w rist

IP

NT

Plaste r of Paris rolls Tube bandage

cm or

cm

cm in dispe nse r box

3 Cre pe pape r bandage 4 Cast padding 5 Cut tube bandage 6 Scissors Oscillating saw Cast spre ade r Surgical tape or bandage clips Elastic bandage

P

S NN

1 36

ppe r e xtre mit Short arm cast using plaste r of Paris

e

n

i

e

5

P SITI NIN

Se at the patie nt com fortabl on a stool Place the affe cte d arm on the table , in a functional position

SP CI

T IN S T

P IN

IN

• ree exion of th e elbow sh ou ld be possible • etacarpal h eads sh ou ld rem ain free • Th e distal palm ar crease sh ou ld rem ain free • h ile th e cast is settin g th e lim b sh ou ld be position ed h alfw ay betw een su pin ation an d pron ation • In prim ary fractu re care it is n ecessary to split th e cast com pletely open after settin g or in th e case of se ere sw ellin g to rem o e a sm all strip

36

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

C

Trim the tube bandage a fe w ce ntim e te rs above the nge rtips

Cut a se cond ope ning ove r the PIP oint of the inde x nge r to fold bac ove r the thum b late r

Appl the padding ma e a hole for the thum b rst

rap the fore arm using the half ove rlapping te chni ue

Appl the pape r bandage m a e a te ar to accomm odate the thum b

se the pape r bandage to form a barrie r be twe e n the dr padding and the we t POP

Subm e rge the roll of POP in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Appl the rst roll of POP

n

Cut an ope ning for the thum b

e

Appl the tube bandage

i

e

5

P

a lf ove rla p p in g

rap the fore arm using the half ove rlapping te chni ue

36

ppe r e xtre mit

e

n

i

e

5

Short arm cast using plaste r of Paris

Cut halfwa through, from proximal to distal, for e asie r application be twe e n the thum b and inde x nge r

rap the fore arm using the half ove rlapping te chni ue

Mold and sm ooth out the cast

old bac the tube bandage ove r the rst la e r of POP distall

Pass the thum b through the hole in the tube bandage and fold it ove r the POP

Appl anothe r la e r of POP If e xtra stabilit is ne e de d, m ore splint can be adde d

old bac the e nd of the POP

Mold the cast to the re uire d shape

Mold the e dge s of the cast for a sm ooth nish

3

Ensure the m e tacarpal he ads are fre e to allow m ove m e nt of the nge rs and thum b

e t hands m a e sm oothing the cast e asie r

Split the cast with an oscillating saw

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Dire ct the saw to avoid the bon promine nce s

Mar the splitting line

Split the cast from proxim al to distal

Ope n the cast with the cast spre ade rs

Cut through the padding and the tube bandage with the scissors

Appl an e lastic bandage to x the cast

rap the fore arm using the half ove rlapping te chni ue

Se cure the bandage with surgical tape or bandage clips

e

n

The saw blade oscillate s and doe s not rotate , so the re is no dire ct harm to the s in

i

e

5

Klaus Dre sing, os Engele n

Ensure fre e m ove m e nt of the nge rs and thum b is possible

3

ppe r e xtre mit Short arm cast using plaste r of Paris

P

C

or patie nts with se ve re swe lling, cut out a strip of the POP cast

ill the space with padding to avoid gap e de m a

rap the fore arm using the half ove rlapping te chni ue

Se cure the bandage with surgical tape or bandage clips

rap the cast with an e lastic bandage

e

n

i

e

5

SP CI

IN

SS SS

NT

re e e xion of the e lbow

The cast should e nd two nge r s bre adth from the e lbow cre ase

re e m ove m e nt of the thum b

re e e xion of the nge rs at the MCP oints

3

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

5

Short arm cast using s nthetic, combicast techni ue

IN IC TI N

•

ractu re of th e distal radiu s

• Stabilization of th e distal forearm an d w rist

IP

NT

Semirigid casting tape

cm

igid s nthe tic splint

cm x

3

Cut tube bandage s

4

Tube bandage

5

Tube bandage

6

Elastic foam tape

cm

cm in dispenser box cm in dispe nse r box

Scissors love s Elastic bandage

P

S NN

1 3 3

ppe r e xtre mit Short arm cast using s nthe tic, combicast te chni ue

e

n

i

e

5

P SITI NIN

Se at the patie nt com fortabl on a stool Place the affe cte d lim b on the table , in a functional position

SP CI

T IN S T

P IN

IN

• ree exion of th e elbow sh ou ld be possible • etacarpal h eads sh ou ld rem ain free • Th e distal palm ar crease sh ou ld rem ain free • h ile th e cast is settin g th e lim b sh ou ld be position ed h alfw ay betw een su pin ation an d pron ation • In prim ary fractu re care it is n ecessary to split th e cast com pletely open after settin g or in th e case of se ere sw ellin g to rem o e a sm all strip

3 4

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

C

le x the nge rs to allow the e xce ss tube bandage to be cut

Appl a small tube bandage ove r the thum b

Appl a pie ce of e lastic foam tape , with an ope ning for the prom ine nt bone , to re duce pre ssure on the ulnar st loid proce ss

Appl a se cond pie ce of e lastic foam tape for e xtra prote ction

The radial st loid proce ss is also prote cte d with e lastic foam tape

sing we t glove s m a e s it e asie r to appl the se m irigid casting tape

Appl the rst la e rs of se m irigid casting tape

Ensure the m e tacarpal he ads re main fre e

Cut halfwa through the casting tape , from proxim al to distal, for a sm ooth application be twe e n the thum b and inde x nge r

Ensure the distal palm ar cre ase re m ains fre e

n

Cut an ope ning for the thum b

e

Appl the tube bandage

i

e

5

P

3 5

ppe r e xtre mit

5

Short arm cast using s nthe tic, combicast te chni ue

rap the fore arm using the half ove rlapping te chni ue

old bac the tube bandage ove r the proxim al and distal e dge s of the se m irigid casting tape

e

n

i

e

a lf o ve rla p p in g

3 6

Appl a rigid splint, and if ne ce ssar , trim to the de sire d shape

Shape the rigid splint li e this the splint can be use d we t or dr

Subm e rge the rigid splint in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Appl the rigid splint, and m old into place

Ensure the distal palm ar cre ase re m ains fre e

Appl an additional la e r of se m irigid casting tape using the half ove rlapping te chni ue

Cut halfwa through the casting tape , from proxim al to distal, for a sm ooth application be twe e n the thum b and inde x nge r

Subm e rge the e lastic bandage in wate r using a we t bandage acce le rate s the se tting

rap the fore arm using the half ove rlapping te chni ue

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

e

5

Klaus Dre sing, os Engele n

IN

SS SS

i

e move the we t bandage after the cast has se t

n

Mold to the palm ar cre ase

e

old the wrist in dorsal e xion while se tting the nge rs should be spre ad to cre ate e nough space in the cast

NT

re e e xion of the nge rs at the MCP oints

Pre cise nge r m ove m e nts are possible

unctional position with the wrist

dorsal e xion in

The cast should e nd two nge r s bre adth from the e lbow cre ase to allow fre e e xion of the e lbow

3

ppe r e xtre mit Short arm cast using s nthe tic, combicast te chni ue

Pre ss on both side s to cre ate a sm all space for the scissors

Split the cast from distal to proxim al, and re m ove

e

n

i

e

5

C ST

3

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

5

3

Thumb spica splint using plaster of Paris

IN IC TI N

• •

ractu re of th e rst m etacarpal ractu re of th e scaph oid

• Stabilization of rst n ger ray

IP

NT

Plaste r of Paris splint Tube bandage 3 Tube bandage

cm or

cm

cm in dispe nser box cm in dispe nse r box

4 Cre pe pape r bandage 5 Elastic bandage 6

au e bandage Cast padding Cut tube bandage s Scissors Surgical tape or bandage clips

P

S NN

1 3

ppe r e xtre mit

P SITI NIN

e

n

i

e

5

3

Thumb spica splint using plaste r of Paris

Se at the patie nt com fortabl on a stool Place the affe cte d lim b on the table , in a functional position

SP CI

T IN S T

P IN

IN

• Th e I join t of th e th u m b rem ain s free • ree exion of th e elbow sh ou ld be possible • Th e distal palm ar crease sh ou ld rem ain free • h ile th e splin t is settin g th e lim b sh ou ld be position ed h alfw ay betw een su pin ation an d pron ation

3

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

C

Cut anothe r hole to allow the tube bandage to be pulle d bac ove r the thum b late r

Appl a small tube bandage ove r the thum b

Appl the padding ma e a hole for the thum b rst

Ma e a split halfwa through the padding, from proximal to distal, to ensure smooth prote ction be twe e n the thumb and inde x nger

n

Cut a hole in the tube bandage for the thum b

e

Appl the tube bandage

i

e

5

P

3

Klaus Dre sing, os Engele n

a lf ove rla p p in g

rap the fore arm using the half ove rlapping te chni ue

Cut halfwa through the bandage , from proxim al to distal, for e as application be twe e n the thum b and the inde x nge r

Appl the pape r bandage to form a barrie r be twe e n the dr padding and the we t POP

rap the fore arm using the half ove rlapping te chni ue

Appl the POP splint, and trim to the re uire d shape

3

ppe r e xtre mit

Shape the splint li e this

old the splint and subm e rge in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Appl the splint and m old to the arm

rap the splint be twe e n the thum b and inde x nge r

Appl the bandage , cut halfwa through, from proxim al to distal, for e as application be twe e n the thum b and the inde x nge r

rap the fore arm using the half ove rlapping te chni ue

old the splint in the de sire d position during se tting, with the thum b and inde x nge r in opposition

Position the fore arm halfwa be twe e n supination and pronation

e

n

i

e

5

3

Thumb spica splint using plaste r of Paris

3

Stretch and smooth out the splint, pressing the la ers together, resulting in a compact splint If this procedure is not done, puff pastr plaster will result, causing an unstable splint

Subm e rge the gau e bandage in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

old bac the tube bandage proxim all

Place the thum b and inde x nge r in opposition, as if holding a baton

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Split the splint com ple te l with scissors

old bac the tube bandage distall , and hold in place with the e lastic bandage

Se cure the bandage with surgical tape or bandage clips

The distal palm ar cre ase is fre e

The splint should e nd two nge r s bre adth from the e lbow

e

n

Tap the splint to che c it has se t

i

e

5

3

Klaus Dre sing, os Engele n

Appl an e lastic bandage to close the splint and hold it in position

IN

SS SS

NT

Opposition of the thum b and inde x nge r is possible re e m ove m e nt of the IP oint of the thum b is possible

3 3

ppe r e xtre mit

e

n

i

e

5

3

Thumb spica splint using plaste r of Paris

3 4

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

5

4

Thumb spica splint using s nthetic

IN IC TI N

• •

ractu re of th e rst m etacarpal ractu re of th e scaph oid

• Stabilization of rst n ger ray

IP

NT

igid s nthe tic splint cm x cm

cm or

Cut tube bandage s 3 Tube bandage 4 Tube bandage

cm in dispe nse r box cm in dispe nser box

5 Cast padding 6 Elastic bandage au e bandage Scissors love s Surgical tape or bandage clips

P

S NN

1 3 5

ppe r e xtre mit

P SITI NIN

e

n

i

e

5

4

Thumb spica splint using s nthe tic

Se at the patie nt com fortabl on a stool Place the affe cte d lim b on the table , in a functional position

SP CI

T IN S T

P IN

IN

• Th e I join t of th e th u m b rem ain s free • ree exion of th e elbow sh ou ld be possible • Th e distal palm ar crease sh ou ld rem ain free • h ile th e splin t is settin g th e lim b sh ou ld be position ed h alfw ay betw een su pin ation an d pron ation

3 6

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

C

Cut a hole in the tube bandage for the thum b

Place a sm all tube bandage ove r the thum b

Appl the padding m a e a hole for the thum b rst

Ma e a te ar in the padding to e nsure sm ooth prote ction be twe e n the thum b and inde x nge r

rap the fore arm using the half ove rlapping te chni ue

A pape r bandage is not ne e de d as s nthe tic m ate rial is use d Che c the le ngth of splint, and trim to the de sire d shape

Shape the splint li e this

e

n

Appl the tube bandage sm oothl and without wrin le s

i

e

5

P

4

Klaus Dre sing, os Engele n

a lf ove rla p p in g

Subm e rge the splint in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Appl the splint be gin at the distal palmar cre ase

3

ppe r e xtre mit

Place the splint around the thum b

Subm e rge a gau e bandage in wate r

e

n

i

e

5

4

Thumb spica splint using s nthe tic

3

Appl the gau e bandage to hold the splint in place

rap the fore arm using the half ove rlapping te chni ue

hile the splint se ts, the lim b should be positione d halfwa be twe e n supination and pronation

Position the hand as if holding a baton

old bac the tube bandage , proxim all and distall

Mold the splint and hold in position until it is se t

Tap on the splint to che c it has se t

Mar the splitting line

Split the splint com ple te l with scissors, and close with an e lastic bandage

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

n

Se cure the bandage with surgical tape or bandage clips

e

rap the fore arm using the half ove rlapping te chni ue

i

e

5

4

Klaus Dre sing, os Engele n

IN

SS SS

NT

The splint should e nd two nge r s bre adth from the e lbow

Opposition of the thum b and the inde x nge r is possible

re e m ove m e nt of the e lbow and the IP oint of the thum b are possible

The thum b is prote cte d

The distal palm ar cre ase is fre e to allow unre stricte d m ove m e nt of the nge rs

3

ppe r e xtre mit

e

n

i

e

5

4

Thumb spica splint using s nthe tic

3

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

5

5

Short arm cast using plaster of Paris with traction and reduction

IN IC TI N

•

isplaced fractu re of th e distal radiu s

• Stabilization of th e w rist

IP

NT

A weight Plaste r of Paris rolls 3 Plaste r of Paris splint 4 Tube bandage

cm or cm or

cm cm

cm in dispenser box

5 Cre pe pape r bandage 6 Traction sling Elastic bandage au e bandage Cast padding inger traps Cut tube bandage Scissors 3 Surgical tape or bandage clips

P

S NN

3

ppe r Extremit

P SITI NIN

e

n

i

e

5

5

Short arm cast using plaste r of Paris with traction and re duction

Place the patie nt supine on a table The affe cte d arm is he ld in abduction b the surge on, with e xion of the e lbow

SP CI

T IN S T

P IN

IN

• Th e distal palm ar crease rem ain s free • ree exion of th e elbow • Th e redu ction is perform ed an d h eld by th e su rgeon • ray du rin g redu ction is ad isable bu t at th e en d is m an datory

3

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

C

e

5

P

5

Klaus Dre sing, os Engele n

Dire ction of the traction is ove r the rst and se cond ra ith the surge on providing continuous te nsion and support, appl the nge r traps

e pe at for the inde x nge r

Place a traction sling ove r the bice ps

i

Place a sm all tube bandage ove r the thum b

n

Appl the tube bandage the wrist ne e ds to be stabili e d b the surge on at all tim e s

e

Appl the tube bandage be fore starting the traction Cut a hole in the tube bandage for the thum b

Com pre ss the sle e ve to wide n it and place ove r the thum b

Attach the nge r traps to the traction s ste m

Appl a we ight for traction

More we ight is ne ce ssar for m ore athle tic or obe se patie nts, also for patie nts that are not re laxe d

3 3

ppe r Extremit

Afte r appl ing the we ight, the traction re sults in disim paction of the fracture

e ave the uppe r e xtre m it unde r traction for to minute s

lnar abduction of le ads to le ss com pre ssion on the fracture d radius

e

n

i

e

5

5

Short arm cast using plaste r of Paris with traction and re duction

The proce ss involve s ste p b ste p traction and re duction of the fracture ge ar whe e l m e chanism

ragm e nts are re duce d dorsall

irst, move the hand dorsall under e xtension the dorsal aspe ct of the fragments are positione d dire ctl above e ach other

3 4

The im pacte d fracture

Disim paction b traction and te nsion

The fragm e nt is rolle d ove r to the palm ar side

The fracture gap is close d and com ple te l re duce d

Move the wrist to the functional position unde r furthe r te nsion, and the n re le ase the e xte nsion

Place the wrist in slight palmar e xion and ulnar abduction to re tain the re sult of the re duction

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

rap the fore arm using the half ove rlapping te chni ue

Appl the pape r bandage to form a barrie r be twe e n the dr padding and the we t POP

Cut halfwa through the bandage , from proxim al to distal, for e as application be twe e n the thum b and inde x nge r

rap the fore arm using the half ove rlapping te chni ue

Subm e rge a roll of POP in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Appl the roll of POP

Cut halfwa through, from proxim al to distal, for e asie r application be twe e n the thum b and the inde x nge r

rap the fore arm using the half ove rlapping te chni ue

Subm e rge the POP splint in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

e

Appl the padding ma e a te ar from proximal to distal to ensure smooth prote ction be twe e n the thumb and inde x nger

n

e fore xation, the tube bandage is pulle d down ove r the fore arm

i

e

5

5

Klaus Dre sing, os Engele n

a lf ove rla p p in g

3 5

ppe r Extremit

Stretch and smooth out the splint, pressing the la ers together, resulting in a compact splint If this procedure is not done, puff pastr plaster will result, causing an unstable splint

Appl the splint dorsall

Mold the splint and fold bac the tube bandage , proximall and distall

Appl anothe r we t roll of POP old the re duction while the roll of POP is applie d

Cut halfwa through for e asie r application be twe e n the thum b and inde x nge r

Mold the cast into the nal position

e

n

i

e

5

5

Short arm cast using plaste r of Paris with traction and re duction

e t hands m a e sm oothing the cast e asie r

e m ove the nge r traps afte r the cast has se t Mar the splitting line

3 6

Appl pre ssure to the distal radius using the thum bs while the cast is m olde d

he n using the oscillating saw, ta e care of the prom ine nt bone s the radial and ulnar st loid proce sse s and m e tacarpal he ads

old the re duction until the cast is se t

The saw blade oscillate s and doe s not rotate , so the re is no dire ct harm to the s in

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

e

5

5

Klaus Dre sing, os Engele n

i

Com ple te the splitting b cutting the padding and the tube bandage with scissors

n

ide n the split with the cast spre ade r

e

Split the cast from distal to proxim al

Che c that the cast is com ple te l split

Appl an e lastic bandage to se cure the cast

rap the fore arm using the half ove rlapping te chni ue

Se cure the bandage with surgical tape or bandage clips

3

ppe r Extremit

IN

SS SS

NT

re e e xion of the e lbow

The cast should e nd two nge r s bre adth from the e lbow cre ase

re e m ove m e nt of the thum b

X ra re vie w is m andator

re e e xion of the nge rs at the MCP oints

e

n

i

e

5

5

Short arm cast using plaste r of Paris with traction and re duction

3

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

5

6

Short arm scaphoid cast using s nthetic, combicast techni ue

IN IC TI N

• •

ractu re of rst m etacarpal ractu re of th e scaph oid

• Stabilization of th e carpal bon es an d th e rst n ger ray

IP

NT

igid s nthe tic splint

cm x

cm

Cut tube bandage s 3

Tube bandage

cm in dispe nse r box

4

Tube bandage

5

Semirigid casting tape

6

Elastic foam tape

cm in dispenser box cm

Scissors love s Elastic bandage

P

S NN

1 3

ppe r e xtre mit

P SITI NIN

e

n

i

e

5

6

Short arm scaphoid cast using s nthe tic, combicast te chni ue

Se at the patie nt com fortabl on a stool Place the affe cte d arm on the table , in a functional position

SP CI

T IN S T

P IN

IN

• Th e distal palm ar crease sh ou ld rem ain free • etacarpal h eads sh ou ld rem ain free • ree exion of th e elbow sh ou ld be possible • h ile th e cast is settin g th e lim b sh ou ld be position ed h alfw ay betw een su pin ation an d pron ation

4

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

C

Cut a hole in the tube bandage for the thum b

Place a sm all tube bandage ove r the thum b

Pull the tube bandage lightl , e x the nge rs and trim the bandage to the appropriate le ngth

Exte nd the nge rs with the tube bandage now at the corre ct le ngth

Appl a pie ce of e lastic foam tape ove r the ulnar st loid proce ss, with an ope ning for the prom ine nt bone

Appl a se cond pie ce of e lastic foam tape for e xtra prote ction

Appl m ore e lastic foam tape to prote ct the radial st loid proce ss

e t glove s m a e it e asie r to appl the se m i rigid casting tape

Appl the rst la e r of se m irigid casting tape

The se cond wrap should be at the sam e le ve l as the rst

The m e tacarpal he ads should re main fre e

e

n

Appl the tube bandage sm oothl without wrin le s

i

e

5

P

6

Klaus Dre sing, os Engele n

4

ppe r e xtre mit

e

n

i

e

5

6

Short arm scaphoid cast using s nthe tic, combicast te chni ue

4

Cut the semirigid casting tape halfwa through, from proximal to distal, for smooth application between the thumb and inde x nger

Pull the sm all tube bandage lightl , and wrap the se m irigid casting tape around the thum b, le aving the IP oint fre e

rap the fore arm using the half ove rlapping te chni ue

old bac the tube bandage ove r the se mi rigid casting tape

Pre pare the rigid splint Trim the splint to the de sire d shape

Shape the splint li e this

Subm e rge the splint in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

old bac the oute r la e r of the splint, from proxim al to distal, to give e xtra stabilit to the thum b

Cut through the fold to avoid pre ssure from wrin le s and for a sm ooth surface

Mold the splint to the hand

Appl the ne xt la e r of se m irigid casting tape use the half ove rlapping te chni ue

Cut halfwa through the semirigid casting tape, from proximal to distal, for smooth application be twe en the thumb and inde x nger

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Subm e rge an e lastic bandage in wate r using a we t bandage acce le rate s the se tting of the cast

rap the fore arm using the half ove rlapping te chni ue

old the hand in the de sire d position until the cast is se t

e m ove the we t bandage afte r the cast has se t

n

Ensure the thum b and inde x nge r can be place d in opposition

e

Ma e sure the nge rs can be e asil spre ad to avoid com pre ssion across the MCP oints

i

e

5

6

Klaus Dre sing, os Engele n

4 3

ppe r e xtre mit

IN

SS SS

NT

Opposition of the thum b and inde x nge r is possible

The cast should e nd two nge r s bre adth from the e lbow cre ase to allow fre e e xion of the e lbow

The IP oint of the thum b is fre e

The m e tacarpal he ads re m ain fre e

e

n

i

e

5

6

Short arm scaphoid cast using s nthe tic, combicast te chni ue

The distal palm ar cre ase re mains fre e to allow a st to be m ade

ull m otion of the nge rs is re taine d

4 4

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

5

Dorsopalmar ulnar gutter short arm splint including two or more ngers using plaster of Paris

IN IC TI N

• •

ractu re of th e proxim al ph alan ges II ractu re of th e m etacarpals II

• Stabilization of th e n gers an d or m etacarpu s

IP

NT

Plaste r of Paris splint Tube bandage 3 Tube bandage

cm or

cm

cm in dispe nse r box cm in dispenser box

4 Cre pe pape r bandage 5 Elastic bandage 6

au e bandage Cast padding Cut tube bandage Scissors Surgical tape or bandage clips

P

S NN

1 4 5

ppe r e xtre mit Dorsopalmar ulnar gutter short arm splint including two or more nge rs using plaste r of Paris

e

n

i

e

5

P SITI NIN

Se at the patie nt com fortabl on a stool Place the affe cte d lim b on the table during application, with the nge rs and MCP oints in the intrinsic plus position

SP CI

T IN S T

P IN

IN

• rotection of th e skin betw een th e n gers to a oid m aceration • Th e splin t sh ou ld be placed o er th e dorsopalm ar side of th e h an d an d n gers • h ile th e splin t is settin g th e lim b sh ou ld be position ed h alfw ay betw een su pin ation an d pron ation • Th e n eigh borin g n ger is in clu ded to en su re effecti e splin tin g of th e fractu red n ger • ircu lation

4 6

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

C

Trim the tube bandage to the re uire d le ngth

Place a sm all tube bandage ove r the ring nge r to avoid m ace ration of the s in

Appl the padding ma e a hole for the thum b rst

rap the fore arm using the half ove rlapping te chni ue

Appl the pape r bandage to form a barrie r be twe e n the dr padding and the we t POP

Cut halfwa through the bandage , from proxim al to distal, for e as application be twe e n the thum b and inde x nge r

old the POP splint in half to give the appropriate le ngth, and trim distall to the width of the hand

To com pe nsate for the diffe re nce in le ngth be twe e n the sm all nge r and ring nge r, cut out a se ction of the splint

n

Cut a hole in the tube bandage for the thum b, and anothe r hole for the inde x and m iddle nge r

e

Appl the tube bandage

i

e

5

P

a lf ove rla p p in g

rap the fore arm using the half ove rlapping te chni ue

4

ppe r e xtre mit

5

Dorsopalmar ulnar gutter short arm splint including two or more nge rs using plaste r of Paris

Subm e rge the POP splint in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Appl the splint, and if ne ce ssar , trim to the de sire d shape Mold as an ulnar gutte r splint

old bac the tube bandage , distall and proxim all , to give sm ooth e dge s

Appl a gau e bandage to hold the splint in place

rap the fore arm using the half ove rlapping te chni ue

Place the hand in the desired position end the bandaged ngers over the thumb and bring the patient s hand into the intrinsic plus position

The nge rtips should be visible

Tap the splint to che c it has se t

Split the splint com ple te l ope n with the scissors

Appl an e lastic bandage to close the splint

e

n

i

e

Shape the splint li e this

Stretch and smooth out the splint, pressing the la ers together, resulting in a compact splint If this procedure is not done, puff pastr plaster will result, causing an unstable splint

4

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

e

5

Klaus Dre sing, os Engele n

IN

SS SS

i

Se cure the bandage with surgical tape or bandage clips

n

rap the fore arm using the half ove rlapping te chni ue

e

Cut halfwa through the bandage , from proxim al to distal, for e as application be twe e n the thum b and inde x nge r

NT

re e e xion of the nge rs and thum b

The splint should e nd two nge r s bre adth from the e lbow cre ase to allow fre e e xion of the e lbow

70–90°

0–20°

15–20°

Che c for capillar re ll

Corre ct intrinsic plus position

4

ppe r e xtre mit

e

n

i

e

5

Dorsopalmar ulnar gutter short arm splint including two or more nge rs using plaste r of Paris

4

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

5

Dorsopalmar ulnar gutter short arm splint including two or more ngers using s nthetic

IN IC TI N

•

ractu re of th e proxim al ph alan ges II • ractu re of th e m etacarpals II

• Stabilization of th e n gers an d or m etacarpu s

IP

NT

igid s nthe tic splint cm x cm

cm or

Cast padding 3

Cut tube bandage

4

Tube bandage

5

Elastic bandage

6

au e bandage

cm in dispe nse r box

Scissors love s Surgical tape or bandage clips

P

S NN

1 4

ppe r e xtre mit Dorsopalmar ulnar gutter short arm splint including two or more ngers using s nthe tic

e

n

i

e

5

P SITI NIN

Se at the patie nt com fortabl on a stool Place the affe cte d lim b on the table during application, with the nge rs and MCP oints in the intrinsic plus position

SP CI

T IN S T

P IN

IN

• rotection of th e skin betw een th e n gers to a oid m aceration • Th e splin t sh ou ld be placed o er th e dorsopalm ar side of th e h an d an d n gers • h ile th e splin t is settin g th e lim b sh ou ld be position ed h alfw ay betw een su pin ation an d pron ation • Th e n eigh borin g n ger is in clu ded to en su re effecti e splin tin g of th e fractu red n ger • ircu lation

4

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

C

Trim the tube bandage to the re uire d le ngth

Place a sm all tube bandage ove r the ring nge r

Appl the padding ma e a hole for the thum b rst

rap the fore arm using the half ove rlapping te chni ue

Pre pare the rigid s nthe tic splint an out the la e rs of the splint to t to the diam e te r of the fore arm

Trim the splint to the de sire d shape

Subm e rge the splint in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Appl the splint, and trim if ne ce ssar

n

Cut a hole in the tube bandage for the thum b, and anothe r hole for the inde x and m iddle nge r

e

Appl the tube bandage

i

e

5

P

a lf ove rla p p in g

Shape the splint li e this

4 3

ppe r e xtre mit

Appl a gau e bandage to hold the splint in place use the half ove rlapping te chni ue

e

n

i

e

5

Dorsopalmar ulnar gutter short arm splint including two or more ngers using s nthe tic

old bac the tube bandage to fre e the nge rtips

IN

SS SS

Mold the splint to the re uired position The ngers and the MCP oints should be in the intrinsic plus position old the splint in position until it is set

Tap the splint to che c it has se t, and split the splint com ple te l ope n with the scissors

Appl an e lastic bandage to hold the splint in position Se cure the bandage with surgical tape or bandage clips

NT

The nge rtips are visible

The splint should e nd two nge r s bre adth from the e lbow cre ase to allow fre e e xion of the e lbow

70–90°

Che c for capillar re ll

0–20°

15–20°

Corre ct intrinsic plus position

4 4

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

5

Palmar short arm splint including the ngers using plaster of Paris

IN IC TI N

• •

ractu re of th e proxim al ph alan ges II ractu re of th e m etacarpals II

• Stabilization of th e n gers an d or m etacarpu s

IP

NT

Plaste r of Paris splint Tube bandage 3 Tube bandage

cm or

cm

cm in dispe nse r box cm in dispenser box

4 Cre pe pape r bandage 5 Elastic bandage 6

au e bandage Cast padding Cut tube bandage s Scissors Surgical tape or bandage clips

P

S NN

1 4 5

ppe r e xtre mit Palmar short arm splint including the nge rs using plaste r of Paris

e

n

i

e

5

P SITI NIN

Se at the patie nt com fortabl on a stool Place the patie nt s arm on the table during application, with the nge rs and MCP oints in the intrinsic plus position

SP CI

T IN S T

P IN

IN

• rotection of th e skin betw een th e n gers to a oid m aceration • Th e splin t sh ou ld be sh aped for m ore stability • h ile th e splin t is settin g th e lim b sh ou ld be position ed h alfw ay betw een su pin ation an d pron ation • ircu lation

4 6

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

C

e

5

P

i

Cut a hole in the tube bandage for the thum b

n

Appl the tube bandage , sm oothl and without wrin le s

e

A roll of bandage m a be use d to support the wrist

old bac the tube bandage and appl additional sm all tube bandage s to prote ct the s in be twe e n the nge rs

Ma e a te ar in the padding to e nsure sm ooth prote ction be twe e n the thum b and inde x nge r

old the tube bandage bac ove r the nge rs

Ensure the re is no com pre ssion across the nge rs

Appl the padding ma e a hole for the thum b rst

Ensure the padding e xte nds past the nge rtips

a lf ove rla p p in g

rap the fore arm using the half ove rlapping te chni ue

Appl the pape r bandage to form a barrie r be twe e n the dr padding and the we t POP

4

ppe r e xtre mit

e

n

i

e

5

Palmar short arm splint including the nge rs using plaste r of Paris

Cut halfwa through the bandage , from proxim al to distal, for e asie r application be twe e n the thum b and inde x nge r

rap the fore arm using the half ove rlapping te chni ue

e place the roll of bandage unde r the wrist to m a e positioning of the hand e asie r

Appl the folde d POP splint, starting or cm be low the e lbow cre ase Trim the splint to the de sire d le ngth and shape

Shape the splint li e this

Subm e rge the POP splint in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Mold the splint to the hand and the fore arm

old bac the tube bandage ove r the splint, proxim all and distall

Appl a gau e bandage to hold the splint in position rap the fore arm using the half ove rlapping te chni ue

e nd the bandage d nge rs ove r our thum b, while our othe r hand brings the patie nt s hand into the intrinsic plus position old the hand position until the splint is se t

Stretch and smooth out the splint, pressing the la ers together, resulting in a compact splint If this procedure is not done, puff pastr plaster will result, causing an unstable splint

Mold the splint to the de sire d position The nge rtips should be visible

4

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

e

5

Klaus Dre sing, os Engele n

rap the fore arm using the half ove rlapping te chni ue Se cure the bandage with surgical tape or bandage clips

i

Appl an e lastic bandage to hold the splint in position

Split the splint com ple te l ope n with the scissors

n

Mar the splitting line

e

Tap the splint to che c it has se t

4

ppe r e xtre mit Palmar short arm splint including the nge rs using plaste r of Paris

SS SS

NT

re e e xion of the e lbow

The splint should e nd two nge r s bre adth from the e lbow cre ase

The re is fre e m ove m e nt of the thum b

e

n

i

e

5

IN

The nge rtips are visible

70–90°

Che c for capillar re ll

0–20°

15–20°

Corre ct intrinsic plus position

4

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

5

Short arm cast including two or more ngers using s nthetic, combicast techni ue

IN IC TI N

•

ractu re of th e proxim al ph alan ges II • ractu re of th e m etacarpals II

• Stabilization of th e n gers an d or th e m etacarpu s

IP

NT

igid s nthe tic splint cm x cm

cm or

Semirigid casting tape

cm

3

Tube bandage

cm in dispe nse r box

4

Tube bandage

5

Elastic foam tape

6

Scissors

cm in dispenser box

Cut tube bandage s love s Elastic bandage

P

S NN

1 4

ppe r e xtre mit Short arm cast including two or more nge rs using s nthe tic, com bicast te chni ue

e

n

i

e

5

P SITI NIN

Se at the patie nt com fortabl on a stool Place the affe cte d lim b on the table during application, with the nge rs and MCP oints in the intrinsic plus position

SP CI

T IN S T

P IN

IN

• •

rotection of th e skin betw een th e n gers to a oid m aceration h ile th e splin t is settin g th e lim b sh ou ld be position ed h alfw ay betw een su pin ation an d pron ation • ircu lation

4

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

C

Cut a se cond hole for the inde x and m iddle nge r

Place a sm all tube bandage ove r the ring nge r

Place an additional small tube bandage to prote ct the thum b

Appl a pie ce of e lastic foam tape to prote ct the bon prom ine nce s the radial and ulnar st loid proce sse s

Appl a se cond pie ce of e lastic foam tape to re duce pre ssure on the ulnar st loid proce ss

Appl additional e lastic foam tape to prote ct the proxim al borde r of the cast

old the rigid splint in half, fan out the proxim al e nd to match the shape of the hand, and cut through the distal e nd

Shape the rigid splint li e this

Subm e rge the se m irigid casting tape in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Appl the se m irigid casting tape , cut halfwa through, from proxim al to distal, for e as application be twe e n the thum b and inde x nge r

n

Cut a hole in the tube bandage for the thum b, and pull the bandage tight to re m ove an wrin le s

e

Appl the tube bandage

i

e

5

P

4 3

ppe r e xtre mit

e

n

i

e

5

Short arm cast including two or more nge rs using s nthe tic, com bicast te chni ue

To avoid folds, cut the casting tape halfwa through, close to the m iddle nge r, and wrap around the ring and sm all nge r twice

rap the se mirigid casting tape around the m idhand

Cut halfwa through the se m irigid casting tape , and wrap once m ore be twe e n the thum b and inde x nge r

a lf o ve rla p p in g

rap the fore arm using the half ove rlapping te chni ue , until half the e lastic foam tape is cove re d

4 4

old bac the tube bandage and the e lastic foam tape ove r the se m irigid casting tape proxim all

old bac the tube bandage ove r the thum b and nge rs

Subm e rge the rigid splint in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Appl the splint, and if ne ce ssar , trim to t the hand The nge rtips should be visible

Cut halfwa through the se m irigid casting tape , from proximal to distal, for e as application be twe e n the nge rs

rap the fore arm using the half ove rlapping te chni ue

Subm e rge an e lastic bandage in wate r for a fe w se conds using a we t bandage acce le rate s the se tting

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

e

5

Klaus Dre sing, os Engele n

i

Trim the cast distall to allow fre e m ove m e nt of the inde x and m iddle nge r

n

Tap the cast to che c it has se t and re m ove the we t bandage

e

old the hand in the de sire d position until the cast is se t

4 5

ppe r e xtre mit Short arm cast including two or more nge rs using s nthe tic, com bicast te chni ue

SS SS

NT

re e m ove m e nt of the inde x and m iddle nge r and the thum b

The nge rtips of the ring and little nge r are visible

e

n

i

e

5

IN

The cast should e nd two nge r s bre adth from the e lbow cre ase to allow fre e e xion of the e lbow

Che c for capillar re ll

70–90°

0–20°

15–20°

Corre ct intrinsic plus position

4 6

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

5

Kleinert d namic splint using plaster of Paris

IN IC TI N

•

esion of a exor ten don

•

ostoperati e fu n ction al treatm en t of a exor ten don lesion

IP

NT

Cast padding Plaste r of Paris splint 3 Tube bandage

cm or

cm

cm in dispenser box

4 Cre pe pape r bandage 5 Elastic bandage 6 Two gau e bandage s Cut tube bandage Safe t pins Pie ce of elastic Scissors Surgical tape or bandage clips

P

S NN

1 4

ppe r e xtre mit Kle ine rt d namic splint using plaster of Paris

e

n

i

e

5

P SITI NIN

Se at the patie nt com fortabl on a stool Place the affe cte d lim b on the table , position the wrist at and the nge rs at palm ar e xion

SP CI

T IN S T

P IN

IN

•

or xation to th e n ail a special glu e or a su tu re th rou gh th e n ail can be u sed • etacarpoph alan geal join ts rem ain free on th e palm ar side

4

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

C

e

5

P

i

Appl the padding, not too tightl , over the tube bandage Ensure the ngers are not pressed together, and preserve the angle of the oints

n

Cut a hole in the tube bandage for the thum b, and trim distall

e

Appl the tube bandage , and stre tch it to re m ove an wrin le s

a lf o ve rla p p in g

Ma e a te ar in the padding to e nsure sm ooth prote ction be twe e n the thum b and inde x nge r

rap the fore arm using the half ove rlapping te chni ue

Appl the pape r bandage to form a barrie r be twe e n the dr padding and the we t POP

Cut halfwa through the bandage for e as application be twe e n the thum b and inde x nge r

rap the fore arm using the half ove rlapping te chni ue

old the POP splint in two to ma e e ight la e rs

Trim the corne rs of the splint proximall and place on the fore arm

Trim the splint distall to t the shape of the hand

4

ppe r e xtre mit

Subm e rge the POP splint in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Appl the splint and m old to the hand and fore arm

old bac the tube bandage ove r the splint proxim all

Appl a gau e bandage to hold the splint in position rap the fore arm using the half ove rlapping te chni ue

old the splint in position while it se ts e nsure that no com pre ssion is applie d across the nge rs

Afte r the splint has se t, cut awa the gau e bandage and the padding on the distal palmar side

Split the tube bandage and fold it ove r the splint

Che c the position and dire ction of the in ure d nge r in the norm al position the nge r points to the scaphoid

Che c that the e xor te ndons can full be nd the nge rtip should com e as close as possible to the distal palmar cre ase

Cut short strips of POP to x the tube bandage in place the should be subm e rge d in wate r one at a tim e

e

43

Stretch and smooth out the splint, pressing the la ers together, resulting in a compact splint If this procedure is not done, puff pastr plaster will result, causing an unstable splint

Shape the splint li e this

n

i

e

5

Kle ine rt d namic splint using plaster of Paris

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Appl an e lastic bandage afte r the splint has se t it will be use d to anchor the safe t pins

Cut halfwa through the bandage , from proxim al to distal, for e as application be twe e n the thum b and inde x nge r

rap the fore arm using the half ove rlapping te chni ue

Se cure the bandage with surgical tape or bandage clips

Attach a safe t pin to the e lastic bandage , distall to the scaphoid, and as close as possible to the distal palmar cre ase

Attach a safe t pin proxim all

Attach a pie ce of elastic to the affe cte d nger with glue or a suture through the nail, or as de monstrate d here, with a small velcro strip

Thre ad the pie ce of e lastic through both safe t pins

Pull the affe cte d nge r into e xion with the e lastic

n

Ensure the distal palm ar cre ase is fre e to allow m ove m e nt of the nge rs

e

old ove r the tube bandage and hold in place with the POP strips

i

e

5

Klaus Dre sing, os Engele n

43

ppe r e xtre mit

Ensure the patie nt is able to e xte nd the nge r without appl ing too m uch force

he n the patie nt re laxe s, the nge r should re turn to the e xe d position

Ensure that com ple te e xte nsion is possible

The re should be fre e m ove m e nt of the unaffe cte d nge rs

Passive e xion and active e xte nsion is possible this he lps to pre ve nt adhe sions that limit e xor te ndon m otion

e

n

i

e

5

Kle ine rt d namic splint using plaster of Paris

Tie the e lastic se cure l to the proxim al safe t pin

IN

SS SS

NT

Ensure the re is not too much te nsion on the e lastic

43

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

5

Kleinert d namic splint using s nthetic, combicast techni ue

IN IC TI N

•

esion of a exor ten don

•

ostoperati e fu n ction al treatm en t of a exor ten don lesion

IP

NT

Elastic foam tape Pie ce of elastic 3 Tube, e g, suction tube 4

igid s nthe tic splint

cm x

cm

5 Cut tube bandage s 6 Tube bandage Tube bandage

cm in dispe nse r box cm in dispenser box

Scissors Se mirigid casting tape

cm

love s Elastic bandage

P

S NN

1 433

ppe r e xtre mit Kle ine rt d namic splint using s nthe tic, combicast te chni ue

e

n

i

e

5

P SITI NIN

Se at the patie nt com fortabl on a stool Place the affe cte d lim b on the table , position the wrist at and the nge rs at palm ar e xion

SP CI

T IN S T

P IN

IN

•

or xation to th e n ail special glu e or a su tu re th rou gh th e n ail can be u sed • etacarpoph alan geal join ts rem ain free on th e palm ar side

434

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

C

e

5

P

Place a sm all tube bandage ove r the thum b

Appl e lastic foam tape to prote ct the bon prom ine nce s, starting with the radial st loid proce ss

Cut a hole in the rst la e r of e lastic foam tape ove r the ulnar st loid proce ss, and appl a se cond la e r for e xtra prote ction

Prote ct the MCP oints with e lastic foam tape

Cut the tubing to the re uire d le ngth

Appl the se m irigid casting tape around the hand

Cut halfwa through the se m irigid casting tape , from proximal to distal, for e as application be twe e n the thum b and inde x nge r

old bac the tube bandage ove r the se m irigid casting tape proxim all , and ove r the thum b

old the rigid splint in half, fan out the proxim al e nd to t the width of the fore arm , and cut through the distal e nd

i

Cut a hole in the tube bandage for the thum b, and trim distall

e

n

Appl the tube bandage , and stre tch it to re m ove an wrin le s

435

ppe r e xtre mit

Shape the splint li e this

Place the splint on the dorsal side , starting ove r the PIP oints

Appl the se mirigid casting tape , starting proxim all

Place the tube at the palm ar side wrap the se m irigid casting tape ove r the tube to hold it in place

Cut the splint partwa through at the wrist to avoid pre ssure from wrin le s

e

n

i

e

5

Kle ine rt d namic splint using s nthe tic, combicast te chni ue

436

Cut halfwa through the semirigid casting tape, Distall , the se m irigid casting tape must be from proximal to distal, for eas application wrappe d unde r the tube be twe en the thumb and inde x nge r

Ensure the de sire d angle of the wrist and nge rs doe s not change be fore continuing, turn the hand

Cut a sm all hole in the se m irigid casting tape and thre ad the tube through it

Appl the e lastic bandage starting proximall

Subm e rge an e lastic bandage in wate r for a fe w se conds using a we t bandage acce le rate s the se tting

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Cut awa a se ction of the splint on the palmar side , down to the distal palm ar cre ase , to fre e the nge rs

Ensure full e xion of the nge rs is possible the dorsal se ction pre ve nts ove re xte nsion

Che c that the e xor te ndons can full be nd the nge rtip should com e as close as possible to the distal palm ar cre ase

Che c the position and dire ction of the in ure d nge r in the norm al position, the nge r points to the scaphoid

Trim the tube distall , and cut a slit in the proxim al e nd of the tube

Attach a pie ce of adhe sive foam padding to prote ct the nge rtip of the affe cte d nge r

Attach a pie ce of e lastic to the affe cte d nge r with glue or a suture through the nail, de m onstrate d he re with a sm all ve lcro strip

Inse rt the e lastic through the tube

Control the te nsion of the e lastic so that e xte nsion of the nge r is possible without appl ing too m uch force

Tie off the e lastic proxim all with the affe cte d nge r in e xion

n

Che c that the splint has se t and re m ove the we t bandage

e

old the wrist and nge rs in the de sire d position until the splint is se t

i

e

5

Klaus Dre sing, os Engele n

43

ppe r e xtre mit Kle ine rt d namic splint using s nthe tic, combicast te chni ue

SS SS

NT

e

n

i

e

5

IN

43

Ensure the re is not too much te nsion on the e lastic

The re should be fre e m ove m e nt of the unaffe cte d nge rs

Passive e xion and active e xte nsion is possible this he lps to pre ve nt adhe sions that lim it e xor te ndon m otion

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

5

3

Metacarpal glove using s nthetic, combicast techni ue

IN IC TI N

•

on displaced or redu cible fractu res of th e fth m etacarpal h ead • Also applicable for fractu res of th e m etacarpal h eads II I in a m odi ed design

• Stabilization of th e m etacarpal h eads

IP

NT

Semirigid casting tape

cm

igid s nthe tic splint

cm x

3

Cut tube bandage s

4

Tube bandage

5

Tube bandage

6

Scissors

cm

cm in dispenser box cm in dispe nse r box

love s Elastic bandage

P

S NN

1 43

ppe r e xtre mit

P SITI NIN

e

n

i

e

5

3

Me tacarpal glove using s nthe tic, combicast te chni ue

Se at the patie nt com fortabl on a stool Place the affe cte d lim b on the table

SP CI

• • •

44

T IN S T

P IN

IN

alm ar aspect is free com plete exion of th e n gers is possible ree m o em en t of th e w rist an d th u m b ree in terdigital space to a oid friction

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

C

e

5

P

3

Klaus Dre sing, os Engele n

i

Cut a se cond hole for the inde x nge r and ring nge r

n

Cut a hole in the tube bandage for the thum b

e

Appl the tube bandage

old bac the tube bandage and place a sm all tube bandage ove r the ring nge r to prote ct the s in be twe e n the nge rs

old the tube bandage bac ove r the nge rs

Place a sm all tube bandage ove r the thum b

Pre pare a rigid splint for the outside of the hand fan it out, and trim to the de sire d shape

Shape the splint li e this

Subm e rge the se m irigid casting tape in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Appl the rst la e r of se m irigid casting tape

Cut the se m irigid casting tape halfwa through, from proxim al to distal, for e as application be twe e n thum b and inde x nge r

Cut halfwa through the se m irigid casting tape and wrap be twe e n the m iddle nge r and ring nge r

44

ppe r e xtre mit

old bac the tube bandage proximall , and trim

old bac the small tube bandage from the thum b le ave the re st in place

Subm e rge the splint in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Position the splint and trim to the de sire d shape

Appl a la e r of we t se m irigid casting tape to hold the splint in place

Cut the se m irigid casting tape halfwa through, from proxim al to distal, and wrap around the affe cte d nge rs

Cut the se m irigid casting tape halfwa through, from proxim al to distal, and wrap be twe e n the thum b and inde x nge r

Subm e rge an e lastic bandage in wate r using a we t bandage acce le rate s the se tting

old the MCP oints of the affe cte d nge rs at while se tting

e m ove the we t bandage afte r the glove has se t

Ensure the MCP oints of the affe cte d nge rs are at and the wrist is full m obile

Cut awa the mate rial on the palm ar side , from ove r the nge rs to the distal palm ar cre ase , to allow fre e e xion of the MCP oints

e

n

i

e

5

3

Me tacarpal glove using s nthe tic, combicast te chni ue

44

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

e

5

3

Klaus Dre sing, os Engele n

i

Ensure e xion at the MCP oints is possible

n

Cut along the MCP oints on the palm ar side to allow fre e e xion of the nge rs

e

Trim ming be gins dorsall with sm all scissors

IN

SS SS

NT

le xion is possible and e xte nsion is limite d

443

ppe r e xtre mit

e

n

i

e

5

3

Me tacarpal glove using s nthe tic, combicast te chni ue

444

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

5

4

emovable thumb orthosis using s nthetic

IN IC TI N

•

igam en tou s ru ptu re of th e rst m etacarpoph alan geal join t

• Stabilization of th e rst m etacarpoph alan geal join t

IP

NT

Semirigid casting tape

cm

Adapte d adhe sive ve lcro strips hoo and loop 3

Cut tube bandage s

4

Tube bandage

5

Tube bandage

6

Scissors

cm in dispenser box cm in dispe nse r box

love s Elastic bandage

P

S NN

1 445

ppe r e xtre mit

P SITI NIN

e

n

i

e

5

4

e movable thumb orthosis using s nthe tic

Se at the patie nt com fortabl on a stool Place the affe cte d lim b on the table with the thum b in opposition

SP CI

T IN S T

P IN

IN

• rist sh ou ld rem ain free • In terph alan geal join t of th e th u m b sh ou ld rem ain free

446

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

C

e

5

P

4

Klaus Dre sing, os Engele n

Place a sm all tube bandage ove r the thum b

Pre pare two adhe sive ve lcro strips of diffe re nt widths, one hoo and one loop, and place toge the r, ove rlapping on one side

As a ligam e nt in ur doe s not usuall ne e d rigid splint support, onl se m irigid casting tape is applie d

sing we t glove s m a e s application of the se m irigid casting tape e asie r

Appl the se m irigid casting tape , be ginning be low the thum b

ollow the MCP oints and pass the se mirigid casting tape be twe e n the thum b and inde x nge r and across the distal palm ar cre ase

rap the se m irigid casting tape twice around the thum b

Continue wrapping until all gaps are cove re d

i

Place the nge rs in e xte nsion and the thum b in the de sire d position

n

Cut a hole in the tube bandage ove r the MCP oint of the thum b, and slide the thum b through the hole

e

Appl the tube bandage

e m ove the adhe sive prote ction la e rs

44

ppe r e xtre mit

e

n

i

e

5

4

e movable thumb orthosis using s nthe tic

44

Place the com bine d ve lcro strips on the se m irigid casting tape and wrap with anothe r la e r of se m irigid casting tape

Im portant while xing the ve lcro strips with anothe r la e r of se m irigid casting tape , e e p the sam e borde rs as the rst la e r

Subm e rge an e lastic bandage in wate r for a fe w se conds using a we t bandage acce le rate s the se tting

Appl the we t e lastic bandage

Place the thum b in opposition while the orthosis se ts

Support the thum b on the ulnar side to re duce stre ss on the ulnar collate ral ligam e nt

Tap on the orthosis to che c it has se t, and re m ove the we t bandage

e m ove the orthosis be fore trim m ing it to the de sire d shape The rst ste p is to ope n the ve lcro

Place the scissors unde rne ath the oute r la e rs of se m irigid casting tape whe re the ve lcro ove rlaps, and cut through the tape

Ope n and fold bac the ve lcro the lowe r la e r of se m irigid casting tape can be se e n

The patie nt holds the ve lcro in place

Place the scissors unde r the tube bandage , and cut through the lowe r la e r of se m irigid casting tape and tube bandage

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

e

5

4

Klaus Dre sing, os Engele n

i

Close the orthosis and trim to the de sire d shape

n

e m ove the orthosis

e

The ve lcro strips are on e ithe r side of the orthosis, which can now be ope ne d and close d e asil

Trim the proxim al e dge of the orthosis to allow fre e m ove m e nt of the wrist

Trim the orthosis to allow fre e m ove m e nt of the IP oint of the thum b

Trim the distal e dge s to allow fre e m ove m e nt of the MCP oints

The contours of the hand can be cle arl se e n in the orthosis

Ope n the ve lcro and slide the orthosis ove r the thum b

To give support to the in ur , pull on the uppe r ve lcro strip to close the orthosis

The re should be e nough fre e dom of m ove m e nt to bring the thum b and inde x nge r into opposition

44

ppe r e xtre mit

IN

SS SS

NT

re e m ove m e nt of the wrist and nge rs

re e e xion of the nge rs

e

n

i

e

5

4

e movable thumb orthosis using s nthe tic

45

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

5

5

emovable nger splint using s nthetic

IN IC TI N

•

ractu re of th e in term ediate ph alan x or ligam en tou s ru ptu re of th e proxim al in terph alan geal join t

• Stabilization of th e proxim al in terph alan geal join t

IP

NT

Semirigid casting tape Cut tube bandage 3

Tube bandage

4

Small scissors

5

Scissors

6

love s

cm cm

cm in dispenser box

Elastic bandage Adhe sive and nonadhe sive ve lcro

P

S NN

1 45

ppe r e xtre mit

P SITI NIN

e

n

i

e

5

5

e movable nge r splint using s nthe tic

Se at the patie nt com fortabl on a stool Place the affe cte d lim b on the table

SP CI

T IN S T

P IN

IN

• Th e splin t sh ou ld co er as m u ch of th e proxim al ph alan x as possible • ree m o em en t of th e m etacarpoph alan geal join t • Space is m ade for th e n ail

45

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

C

Cut along the le ngth of the tube bandage , le ave e nough m ate rial uncut to cove r the nge r

Place the tube bandage ove r the nge r and position the not ove r the nge rnail

Subm e rge the se m irigid casting tape in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

rap the nge r with thre e la e rs of se m irigid casting tape , using the half ove rlapping te chni ue

Place an adhe sive strip of ve lcro with loops on the dorsal side

Subm e rge an e lastic bandage in wate r using a we t bandage acce le rate s the se tting

Ensure the not is still on the nge rnail

e m ove the we t bandage whe n the splint has se t

n

Ma e a not at one e nd of the tube bandage , and trim the e xce ss

e

Place the nge r in the functional position

i

e

5

P

5

Klaus Dre sing, os Engele n

a lf ove rla p p in g

Appl the bandage with the nge r place d in a functional position with slight e xion of the PIP and DIP oints

453

ppe r e xtre mit

Cut a slit in the splint with the scissors to m a e re m oval e asie r

Trim the proxim al e nd of the splint

Cut a slit in the splint up to the DIP oint on the palm ar side

e

n

i

e

5

5

e movable nge r splint using s nthe tic

e m ove the se ction of the splint that cove rs the palmar distal phalanx, along with the not

Ma e an ne ce ssar

nal ad ustm e nts that are

ide n the split in the splint

Ma e a nal che c to e nsure fre e m ove m e nt of the DIP oint

Place the splint bac on the nge r e nsure the re is fre e m ove m e nt of the distal phalanx

Appl ve lcro strips with hoo s or adhe sive tape to close the splint

If functional tre atm e nt is allowe d, the distal ve lcro strip can be re m ove d to allow fre e e xion and e xte nsion

454

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

SS SS

NT

e

5

IN

5

Klaus Dre sing, os Engele n

e

n

i

Che c for capillar re ll

455

ppe r e xtre mit

e

n

i

e

5

5

e movable nge r splint using s nthe tic

456

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

5

6

Mallet nger splint using s nthetic

IN IC TI N

• Exten sor ten don in ju ry at th e distal in terph alan geal join t m allet or baseball n ger

•

u ll exten sion of th e distal in terph alan geal join t

IP

NT

Semirigid casting tape Cut tube bandage 3

Tube bandage

4

Small scissors

5

Scissors

6

love s

cm cm

cm in dispenser box

Elastic bandage Surgical tape

P

S NN

1 45

ppe r e xtre mit

P SITI NIN

e

n

i

e

5

6

Malle t nge r splint using s nthe tic

Se at the patie nt com fortabl on a stool Place the affe cte d lim b on the table

SP CI

T IN S T

P IN

IN

• A oid h yperexten sion of th e distal in terph alan geal join t • ail bed sh ou ld be free • lexion of th e proxim al in terph alan geal join t sh ou ld be possible

45

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

C

e

5

P

6

Klaus Dre sing, os Engele n

Me asure e nough se m irigid casting tape to re ach from PIP oint to PIP oint, sagittall

old ove r the se mirigid casting tape to m a e a two la e r splint and trim li e this

Place the splint ove r the nge r, and wrap the nge r with thre e la e rs of se m irigid casting tape , using the half ove rlapping te chni ue

Subm e rge an e lastic bandage in wate r using a we t bandage acce le rate s the se tting

Appl the we t bandage with the nge r in full e xte nsion

n

i

Ma e a not at one e nd of the tube bandage and place it ove r the nge r Position the not ove r the nge rnail

e

Place the affe cte d nge r in full e xte nsion

a lf ove rla p p in g

Mold the e nd of the splint during se tting Ensure the not is still on the nge rnail

e m ove the splint afte r it has se t, and trim to the de sire d shape

re e m ove m e nt of the PIP oint is ne ce ssar

45

ppe r e xtre mit

e m ove a palmar se ction of the splint to allow m ove m e nt of the PIP oint

Ma e an ope ning for the nge rnail

Place the pre pare d splint ove r the nge r Ensure the com ple te nge rnail is fre e

e

n

i

e

5

6

Malle t nge r splint using s nthe tic

Ensure fre e e xion and e xte nsion of the PIP oint is possible

IN

SS SS

NT

re e e xion and e xte nsion of the PIP oint

46

old the splint in place with surgical tape

Control of the capillar re ll

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

TEC NI ower extremit

ES

ower extremit

6

ne and a

a lf le g

ip s p ica ca s t u s in g p la s t e r o f Pa ris

6

Sin gle le g

ip s p ica ca s t u s in g s n t e t ic, co m ica s t t e c n i u e

6 3

C lin d e r lo n g le g ca s t u s in g s n t e t ic , co m ica s t t e c n i u e nee

ra ce

463 4 4

6 4

in ge d

4 3

6 5

o rs a l lo n g le g s p lin t u s in g p la s t e r o f Pa ris

4

6 6

o n g le g ca s t u s in g p la s t e r o f Pa ris

4 5

6

o n g le g ca s t u s in g s n t e t ic, co m ica s t t e c n i u e

5

6

Sa rm ie n t o p a t e lla t e n d o n

e a rin g ca s t u s in g p la s t e r o f Pa ris

6

Sa rm ie n t o t i ia l ra ce u s in g s n t e t ic , co m ica s t t e c n i u e

5 5 3

6

o rs a l s o r t le g s p lin t u s in g p la s t e r o f Pa ris

5

6

o rs a l s o r t le g s p lin t u s in g s n t e t ic

5 5

6

S o r t le g ca s t u s in g rigid s n t e t ic

53

6 3

S o r t le g ca s t u s in g s n t e t ic, co m ica s t t e c n i u e

53

6 4

n t iro t a t io n s o r t le g ca s t u s in g s n t e t ic, co m ica s t t e c n i u e

543

6 5

e m o va le a n le s p lin t u s in g s n t e t ic, co m ica s t t e c n i u e

54

6 6

ift

555

6

e m o va le fift

6

o o t ca s t u s in g s n t e t ic , co m ica s t t e c n i u e

56

6

e m o va le fo o t ca s t u s in g s n t e t ic, co m ica s t t e c n i u e

5 3

6

irs t t o e o r t o s is u s in g s n t e t ic, co m ica s t t e c n i u e

5

m e t a t a rs a l ca s t u s in g s n t e t ic, co m ica s t t e c n i u e m e t a t a rs a l ca s t u s in g s n t e t ic , co m ica s t t e c n i u e

56

Klaus Dre sing, os Engele n

e

n

i

e

6

One and a half leg hip spica cast using plaster of Paris

IN IC TI N

•

ediatric fractu re of th e fem u r

• Stabilization of th e leg an d h ip

IP

NT

Cast padding Plaste r of Paris splint

cm or

cm

3 Plaste r of Paris splint

cm or

cm

4 Plaste r of Paris rolls 5 Tube bandage

cm or

cm

cm in dispe nse r box

6 Cre pe pape r bandage roomstic Cut tube bandage s Scissors Adhe sive tape

P

S NN

3

surge on if ne e de d

463

owe r e xtremit

P SITI NIN

e

n

i

e

6

One and a half le g hip spica cast using plaster of Paris

Patie nt is l ing with the sacrum on a support Place the le gs in a foot support, or he ld b an assistant, e nsure slight e xion of the hip and ne e

SP CI

T IN S T

P IN

IN

• ree m o em en t of th e kn ee on th e con tralateral side • rotection of th e bon y prom in en ces • Sligh t exion of th e h ip an d kn ee join t is n ecessary • Tw o or th ree people are n eeded for th is procedu re

464

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

6

C

Ma e a slit in the proxim al e nd of a long tube bandage , roll it up and appl ove r the affe cte d le g up to the hip

Pull the bandage tight to re m ove an wrin le s

n

Appl padding ove r the stom ach to provide space for bre athing and e ating

e

Appl a tube bandage or cast trouse rs

i

e

P

Appl strips of adhe sive tape to hold the tube bandage in place

a lf o ve rla p p in g

Appl a tube bandage ove r the othe r le g, and hold it in place with strips of adhe sive tape

Appl rolls of padding ove r both tube bandage s using the half ove rlapping te chni ue

Appl the padding down to the an le of the affe cte d le g, and down to the ne e of the othe r le g

Appl a la e r of pape r bandage to cove r all the padding to form a barrie r be twe e n the dr padding and the we t POP

Subm e rge the rolls of POP in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

465

owe r e xtremit

Appl the rolls of POP using the half ove rlapping te chni ue

Sm ooth the POP with we t hands

Appl the rst POP splint from the le ft ne e to the right hip

e

n

i

e

6

One and a half le g hip spica cast using plaster of Paris

Stretch and smooth out the splint, pressing the la ers together, resulting in a compact splint If this procedure is not done, puff pastr plaster will result, causing an unstable splint

POP splints are use d to re inforce the POP cast at spe ci c locations

Start at the nee, pass under the bod , ending above the pelvis on the contralateral side do not pass the splint over the stomach

Appl a longe r, se cond POP splint to the right le g

Appl the splint starting at the an le , and follow the late ral tibia

Continue ove r the fe m ur to the top of the pe lvis, and pass the splint unde r the bod to the contralate ral side

Appl a third splint around the poste rior pe lvis this splint provide s e xtra stabilit

Subm e rge the POP splint in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

466

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Appl the rolls of POP using the half ove rlapping te chni ue , to hold the POP splints in place

e t hands m a e sm oothing the POP e asie r

Sm ooth the com ple te cast and m old whe re ne e de d

Afte r the cast has se t, it is mar e d for re m oval and trimm ing

Cut out the mar e d are a and trim the e dge s

The tube bandage must be folde d ove r the e dge s of the cast

Trim the tube bandage above and be low the cast

Appl e xtra padding to are as whe re it is ne e de d

Push the e dge of the padding unde r the cast and fold bac the tube bandage

The unaffe cte d ne e has com ple te fre e dom of m otion

n

Subm e rge the rolls of POP in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

e

Position of the thre e re inforce m e nt POP splints

i

e

6

Klaus Dre sing, os Engele n

46

owe r e xtremit

e

n

i

e

6

One and a half le g hip spica cast using plaster of Paris

46

old bac the tube bandage ove r the proximal Add padding whe re the se ction of the e dge of the cast cast was re m ove d, and fold bac the tube bandage

Place a pie ce of broom stic on the dorsal aspe ct of the le gs to give adde d stabilit Place the broom stic at an angle , from the he alth to the in ure d le g

Se cure the broom stic to the cast with se ve ral la e rs of POP, using the gure of e ight te chni ue

Se cure the tube bandage in place with a roll of POP

e inforce the attachm e nt of the broom stic to the cast with a roll of POP

Appl strips of adhe sive tape to hold the e dge s of the tube bandage in place

Appl a short strip of POP to attach the folde d ove r tube bandage to the cast

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

NT

6

SS SS

e

IN

e m ove the padding from the stom ach to allow e nough space for fre e bre athing and e ating

Dorsal vie w of the cast

The broom stic re inforce s the structure of the cast

Slight e xion of the hip and ne e is visible

Pre ssure sore s are pre ve nte d b the soft sm ooth e dge s of the cast

Sm ooth e dge s also allow fre e m ove m e nt of the uppe r bod

odil functions are possible

e

n

i

Carr ing out pe rsonal h gie ne is possible

46

owe r e xtremit

e

n

i

e

6

One and a half le g hip spica cast using plaster of Paris

4

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

6

Single leg hip spica cast using s nthetic, combicast techni ue

IN IC TI N

•

ediatric fractu re of th e fem u r

• Stabilization of th e leg an d h ip

IP

NT

igid s nthe tic splint or cm x cm Se mirigid casting tape

cm x cm or

cm cm

3 Adhe sive foam padding 4 Tube bandage

cm in dispe nse r box

5 Scissors 6 Cut tube bandage s love s Elastic bandage Adhe sive tape Elastic foam tape

P

S NN

3

surge on if ne e de d

4

owe r e xtremit

P SITI NIN

e

n

i

e

6

Single le g hip spica cast using s nthe tic, combicast te chni ue

Patie nt is l ing with the sacrum on a support Place the le gs in a foot support, or he ld b an assistant, e nsure slight e xion of the hip and ne e

SP CI

T IN S T

P IN

IN

• ree m o em en t of th e h ip on th e con tralateral side • rotection of th e bon y prom in en ces • Sligh t exion of th e h ip an d kn ee join t is n ecessary • Tw o or th ree people are n eeded for th is procedu re • Th e greater stability of syn th etic m aterial allow s m in im izin g th e h ip spica cast con tralateral leg is n ot in clu ded

4

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

6

C

Ma e a slit in the proximal e nd of a long tube bandage , roll it up and appl ove r the affe cte d le g up to the hip

Pull the bandage tight to re m ove an wrin le s

Appl a shorte r tube bandage ove r the othe r le g, from the ne e to the hip

Appl strips of adhe sive tape to hold the tube bandage s in place

Appl strips of adhe sive foam padding for adde d prote ction

Place the padding ust unde r the costal arche s to provide a sm ooth e dge whe n it is folde d bac ove r the cast

Appl a se cond strip of padding on the patie nt s bac , at the sam e le ve l as the rst

Add strips of e lastic foam tape to prote ct the prom ine nt are as of the pe lvis

Appl adhe sive foam padding ove r the distal bon prom ine nce s, e nsure it doe s not com ple te l e ncircle the le g

Prote ct all the prom ine nt bone s around the ne e with e lastic foam tape

n

Appl additional padding for the stom ach to provide space for bre athing and e ating

e

Appl a tube bandage or cast trouse rs

i

e

P

4 3

owe r e xtremit

6

Single le g hip spica cast using s nthe tic, combicast te chni ue

sing we t glove s m a e s it e asie r to appl the se m irigid casting tape

e

n

i

e

a lf o ve rla pp ing

4 4

Appl the semirigid casting tape, from proximal and distal, using the half overlapping te chni ue

Subm e rge the rigid splint in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Appl the rst splint along the axis of the affe cte d le g

Place the se cond splint around the pe lvis le ave the contralate ral ve ntral aspe ct of the hip oint fre e Position the splint ove r the sacrum but avoid the pe rine al are a

Subm e rge the se m irigid casting tape in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Appl the se m irigid casting tape to hold the splints in place

Subm e rge an e lastic bandage in wate r using a we t bandage acce le rate s the se tting

Appl the we t bandage from proximal and distal, to cove r the se m irigid casting tape

Tap on the cast to m a e sure it is se t, and re m ove the we t bandage and the e xtra stomach padding

old the foam padding and the tube bandage ove r the cast

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Trim the cast in the inguinal and pe rine al re gion e nsure that the hip oint of the unaffe cte d le g has full range of m otion

Cut through the tube bandage , fold it bac ove r the cast and se cure with strips of adhe sive tape

e m ove an cast that ma hinde r fre e m ove m e nt of the hip

e t se m irigid casting tape is use d to wrap all the e dge s of the cast

Subm e rge an e lastic bandage in wate r

Appl ing a we t bandage acce le rate s the se tting

n

old ove r the tube bandage and foam padding distall and trim

e

Appl strips of adhe sive tape to hold the tube bandage in place

i

e

6

Klaus Dre sing, os Engele n

4 5

owe r e xtremit

IN

SS SS

NT

re e m ove m e nt of the contralate ral le g

The re is e nough space for fre e bre athing and e ating

Dorsal vie w of the cast

e

n

i

e

6

Single le g hip spica cast using s nthe tic, combicast te chni ue

Slight e xion of the hip and ne e is visible

4 6

odil functions are possible

Com bicast te chni ue still allows a wide range of activitie s

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

6

3

C linder long leg cast using s nthetic, combicast techni ue

IN IC TI N

• • • •

ractu re of th e distal fem u r ractu re of th e proxim al tibia ractu re of th e patella igam en tou s ru ptu re of th e kn ee

• Stabilization of th e kn ee join t

IP

NT

Elastic foam tape igid s nthe tic splint 3

Cut tube bandage

4

Tube bandage

5

Semirigid casting tape

6

Scissors

cm or

cm x

cm

cm in dispe nse r box cm or

cm

love s Elastic bandage

P

S NN

1

or

4

owe r e xtremit

P SITI NIN

e

n

i

e

6

3

C linder long le g cast using s nthe tic, combicast te chni ue

Place the patie nt supine on a table Place the an le on a foot re st with

e xion at the ne e

SP CI

T IN S T

P IN

IN

• •

roxim al exten sion lesser troch an ter greater troch an ter istal exten sion tw o n gers proxim al of th e m alleoli to allow free m o em en t of th e an kle • oldin g to th e fem oral con dyles to a oid th e cast slippin g dow n th e patien t s leg • ressu re sore on th e Ach illes ten don • In som e in dication s an assistan t is n eeded to su pport th e kn ee leg

4

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

6

C

e

P

3

Klaus Dre sing, os Engele n

i

e t glove s m a e application of the se m irigid casting tape e asie r

n

Appl e lastic foam tape to prote ct the bon promine nce s around the ne e

e

Appl a tube bandage up to the hip Pull the tube bandage tight to avoid wrin le s

a lf ove rla p p in g

Appl the rst la e r of se m irigid casting tape , from distal to proximal, using the half ove rlapping te chni ue

Ensure the se m irigid casting tape cove rs the le sse r trochante r and gre ate r trochante r

Subm e rge the rigid s nthe tic splint in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Cut the splint in half appl the rst splint m e diall and x in place proxim all with se m irigid casting tape

An assistant m a be ne e de d to hold the splints in place distall

old bac the tube bandage ove r the se m irigid casting tape , proxim all and distall , and trim the e xce ss

Appl the se cond splint dorsall x both splints in place with se m irigid casting tape , using the half ove rlapping te chni ue

4

owe r e xtremit

e

n

i

e

6

3

C linder long le g cast using s nthe tic, combicast te chni ue

Appl a se cond la e r of we t se m irigid casting tape , from distal to proxim al, using the half ove rlapping te chni ue

Appl ing a we t bandage acce le rate s the se tting

Subm e rge an e lastic bandage in wate r

Mold the cast to the fe m oral cond le s, the pate lla, and the poplite al fossa

e m ove the we t bandage afte r the cast has se t Ensure the re is no pre ssure on the pate lla, as the re is no splint in this position

a lf o ve rla pp ing

Mar the splitting line split the cast from distal to the ne e , the n from proxim al to the ne e

rap the split cast with an e lastic bandage start at the ne e using the half ove rlapping te chni ue

Se cure the bandage with surgical tape or bandage clips

4

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

NT

6

SS SS

e

IN

3

Klaus Dre sing, os Engele n

e

n

i

ip oint and an le oint have fre e range of m otion

4

owe r e xtremit

e

n

i

e

6

3

C linder long le g cast using s nthe tic, combicast te chni ue

4

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

6

4

inged nee brace

IN IC TI N

• • • • •

ractu re of th e diaph yseal an d distal fem u r ractu re of th e proxim al tibia n ee dislocation s an d ligam en tou s lesion s As an altern ati e to a prefabricated orth osis Th is h in ged brace is n ot for prim ary care

• Stabilization of th e kn ee allow in g lim ited m otion of kn ee join t • u n ction al treatm en t of th e kn ee

IP

NT

Se mirigid casting tape igid s nthe tic splint 3

Cut tube bandage s

4

Tube bandage

5 6

cm or cm x

cm cm

cm in dispenser box

inge s Elastic foam tape Scissors love s Elastic bandage

P

S NN

1 2 or

4 3

owe r e xtremit

P SITI NIN

e

n

i

e

6

4

inge d ne e brace

Place the patie nt supine on a table Place the ne e on a ne e support in approxim ate l

SP CI

• •

4 4

e xion

T IN S T

P IN

IN

osition in g of th e h in ges axis erfect t of th e proxim al an d distal cast cylin ders

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

6

C

Appl a se cond tube bandage from the foot to the ne e

Appl e lastic foam tape ove r the tibial tube rosit and the bular he ad to prote ct the bon prom ine nce s

Proxim all , no additional padding is ne e de d be cause of the soft tissue cove ring

Appl e lastic foam tape to the distal tibia to stop the cast sliding e nsure the tape doe s not e ncircle the bone

n

Ensure the proxim al cast will le ave the fe m oral cond le s fre e , and will e nd as high as possible

e

Appl a tube bandage from the ne e to the hip Pull the bandage tight to avoid an wrin le s

i

e

P

4

Klaus Dre sing, os Engele n

a lf ove rla p p in g

Appl the rst la e r of se m irigid casting tape , using the half ove rlapping te chni ue , but le ave the ne e oint fre e

Position the hinge s at the ir xation points, the distal fe m ur and the proximal tibia two rigid splints will be place d he re

Appl a wide r roll of se m irigid casting tape to wrap the uppe r le g, using the half ove rlapping te chni ue

Subm e rge the rigid splints in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Appl the rigid splints onl halfwa around the le g

4 5

owe r e xtremit

e

n

i

e

6

4

inge d ne e brace

Appl a la e r of we t semirigid casting tape to x the rigid splint on the lower le g using the half overlapping te chni ue

Subm e rge an e lastic bandage in wate r

Appl ing a we t bandage acce le rate s the se tting

old bac the tube bandage and hold it in place with se m irigid casting tape

Cle ar the ne e of e lastic bandage and tube bandage

4 6

old bac the tube bandage , trim and hold in place with se m irigid casting tape

rap the we t bandage around the uppe r le g

Identif and mar the level of the ne e oint

Appl a la e r of we t se m irigid casting tape to the uppe r le g to x the rigid splint in place

Mold the m ate rial ove r the fe m oral cond le s and the tibial cond le s while it se ts

Position a hinge centere d over the oint and if ne e de d contour to the leg epeat the proce dure with the se cond hinge

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Pre pare a roll of se mirigid casting tape and appl to the lowe r le g

Mount both hinge s and wrap the distal e nds with se m irigid casting tape to hold the m in place

rap the proxim al e nds of the hinge s with se m irigid casting tape

rap a we t e lastic bandage around the ne w la e r of se mirigid casting tape to acce le rate the se tting

Ensure the hinge s allow full e xte nsion and e xion of the ne e

Afte r the casts have se t, e nsure the hinge s are solidl se t in place , and re m ove the we t bandage

n

old bac the e nds of the tube bandage ove r the casts and trim

e

e m ove the we t bandage afte r the casts have se t

i

e

6

4

Klaus Dre sing, os Engele n

4

owe r e xtremit

IN

SS SS

NT

e

n

i

e

6

4

inge d ne e brace

4

re e e xion and e xte nsion of the ne e with unbloc e d hinge s

De pe nding on the in ur , e xion and e xte nsion of the ne e can be lim ite d b bloc ing the hinge s

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

6

5

Dorsal long leg splint using plaster of Paris

IN IC TI N

• •

ractu re of th e tibia ractu res arou n d th e kn ee

• Stabilization of th e kn ee an d low er leg

IP

NT

Cast padding Plaste r of Paris splint 3

Tube bandage

4

Cre pe pape r bandage

5

Cut tube bandage

6

Scissors

cm

cm in dispe nse r box

Elastic bandage au e bandage Surgical tape or bandage clips

P

S NN

2

4

owe r e xtremit

P SITI NIN

e

n

i

e

6

5

Dorsal long le g splint using plaste r of Paris

Place the patie nt prone on a table Place the an le oint in

e xion and the ne e in

SP CI

e xion

T IN S T

P IN

IN

• An assistan t is n ecessary to su pport position in g of th e affected lim b • Atten tion sh ou ld be paid to keep th e an kle join t in a fu n ction al position • h en possible free m o em en t of th e toes • roxim al exten sion lesser troch an ter greater troch an ter

4

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

6

C

rap the le g using the half ove rlapping te chni ue

Appl a pape r bandage to form a barrie r be twe e n the dr padding and the we t POP

rap the le g using the half ove rlapping te chni ue

Me asure the le ngth of POP splint ne e de d, from the toe s to the le sse r trochante r gre ate r trochante r

Subm e rge the POP splint in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

An assistant fans out and m olds the proxim al e nd of the splint

Mold the distal e nd of the splint to the unde rside of the foot and trim to the de sire d shape

n

Appl padding over the tube bandage, starting at the foot Support the nee during application ensure that the an le oint is at exion

e

Appl a tube bandage up to the hip Pull the bandage tight to avoid an wrin le s

i

e

P

5

Klaus Dre sing, os Engele n

a lf ove rla p p in g

a the le g bac on the table

Stretch and smooth out the splint, pressing the la ers together, resulting in a compact splint If this procedure is not done, puff pastr plaster will result, causing an unstable splint

4

owe r e xtremit

Mold the splint to the de sire d shape along the com ple te le ngth

Trim the tube bandage distall and proxim all , and fold bac ove r the splint

Appl a gau e bandage to the lower le g, from distal to proximal, to hold the splint in place

The assistant lifts the le g during application of the gau e bandage

rap the lowe r le g using the half ove rlapping te chni ue

Ensure the ne e is at an le oint at e xion

Ensure the splint is m olde d ove r the Achille s te ndon, both malle oli, the cond le s, and the re is support for the thigh m uscle s

Tap on the splint to che c it has se t

Mar the splitting line , and split all la e rs on the ve ntral side

se the ste p b ste p splitting and xing te chni ue to avoid loss of re duction

e

n

i

e

6

5

Dorsal long le g splint using plaste r of Paris

e xion and the

Place the patie nt in the supine position be fore splitting the splint

4

rap the uppe r le g with a gau e bandage

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

e

6

5

Klaus Dre sing, os Engele n

Se cure the bandage with surgical tape or bandage clips Continue supporting the ne e for a short tim e afte r the splint is close d

i

inish the splitting from proximal and close with the e lastic bandage

Ensure the ne e is supporte d during the splitting and wrapping

n

Continue splitting proximall and close with the e lastic bandage

e

Appl an e lastic bandage distall to close the splint

4 3

owe r e xtremit

IN

SS SS

NT

re e m ove m e nt of the toe s

The splint is form e d around the contours of the le g and foot

The ne e is in is in e xion

e xion and the an le oint

e

n

i

e

6

5

Dorsal long le g splint using plaste r of Paris

The re is suf cie nt support of the thigh m uscle s on the dorsal side

4 4

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

6

6

ong leg cast using plaster of Paris

IN IC TI N

• • •

ractu re of th e distal fem u r ractu re of th e proxim al tibia ractu re of th e tibial sh aft

• Stabilization of th e distal u pper leg an d th e low er leg

IP

NT

Cast padding Plaste r of Paris splint 3 Plaste r of Paris rolls 4 Tube bandage

cm or cm or

cm cm

cm in dispenser box

5 Cre pe pape r bandage 6 Cut tube bandage Scissors Oscillating saw Surgical tape or bandage clips Elastic bandage

P

S NN

2 4 5

owe r e xtremit

P SITI NIN

e

n

i

e

6

6

ong le g cast using plaste r of Paris

Place the patie nt supine or se ate d on a table An assistant supports the affe cte d le g the an le oint in and the ne e in e xion

SP CI

T IN S T

e xion

P IN

IN

• An assistan t is n ecessary to su pport position in g of th e affected lim b • Atten tion sh ou ld be paid to keep th e an kle join t in a fu n ction al position • h en possible free m o em en t of th e toes • roxim al exten sion lesser troch an ter greater troch an ter

4 6

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

6

C

rap the le g using the half ove rlapping te chni ue

se a wide r roll of padding for the uppe r le g to m a e application e asie r

Appl a pape r bandage to form a barrie r be twe e n the dr padding and the we t POP

rap the le g using the half ove rlapping te chni ue

Subm e rge the roll of POP in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Appl the roll of POP starting distall

rap the le g using the half ove rlapping te chni ue

se a wide r roll of POP for the uppe r le g to m a e application e asie r

Me asure out an it up

n

Appl padding ove r the tube bandage , starting at the foot

e

Appl a tube bandage from the foot to the hip Pull the bandage tight to avoid an wrin le s

i

e

P

6

Klaus Dre sing, os Engele n

a lf ove rla p p in g

la e r POP splint and fold

4

owe r e xtremit

e

n

i

e

6

6

ong le g cast using plaste r of Paris

Subm e rge the POP splint in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Appl the POP splint and m old to the unde rside of the foot and the bac of the le g

Subm e rge a roll of POP in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Appl the roll of POP, from distal to proxim al, using the half ove rlapping te chni ue

old bac the tube bandage ove r the cast proxim all , and wrap with POP to hold it in place

Sm ooth the com ple te cast around the le g

old bac the tube bandage ove r the cast distall

Appl a roll of POP to hold the tube bandage in place

Sm ooth the com ple te cast, and m old to the fe m oral cond le s, the pate lla, and the tibial cre st

old the cast in the de sire d position while se tting

e t hands m a e sm oothing the cast e asie r

4

Stretch and smooth out the splint, pressing the la ers together, resulting in a compact splint If this procedure is not done, puff pastr plaster will result, causing an unstable splint

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

The saw blade oscillate s and doe s not rotate , so the re is no dire ct harm to the s in

Split the cast pass late rall to the pate lla

Ma e a se cond split, approxim ate l cm late rall to the rst, to e nsure the re is e nough space for an swe lling

Cut through the padding and the tube bandage com ple te l with the scissors, and re m ove the strip of cast

Cut through an re m aining m ate rial to cre ate a gap in the cast

Pull apart the cast slightl to e nsure it is com ple te l se parate d

Ensure the split passe s late rall to the pate lla and is on the late ral side of the foot

rap the com ple te cast with an e lastic bandage

rap the le g using the half ove rlapping te chni ue

Se cure the bandage with surgical tape or bandage clips

n

Mar the splitting line on the ve ntral side

e

Tap on the cast to m a e sure it has se t

i

e

6

6

Klaus Dre sing, os Engele n

4

owe r e xtremit

IN

SS SS

NT

e

n

i

e

6

6

ong le g cast using plaste r of Paris

5

re e m ove m e nt of the toe s and capillar re ll

Proximal and distal e nds of the cast are smooth to avoid irritation The an le oint is in e xion and the ne e in e xion

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

6

ong leg cast using s nthetic, combicast techni ue

IN IC TI N

• • •

ractu re of th e distal fem u r ractu re of th e proxim al tibia ractu re of th e tibial sh aft

• Stabilization of th e distal u pper leg an d th e low er leg

IP

NT

Cast shoe Elastic foam tape 3

igid s nthe tic splint

4

Cut tube bandage

5

Tube bandage

6

Semirigid casting tape

cm x

cm

cm in dispe nse r box cm or

cm

Scissors love s Elastic bandage

P

S NN

2 5

owe r e xtremit

P SITI NIN

e

n

i

e

6

ong le g cast using s nthe tic, combicast te chni ue

Place the patie nt supine or se ate d on a table An assistant supports the affe cte d le g the an le oint in and the ne e in e xion

SP CI

T IN S T

e xion

P IN

IN

• An assistan t is n ecessary to su pport position in g of th e affected lim b • Atten tion sh ou ld be paid to keep th e an kle join t in a fu n ction al position • h en possible free m o em en t of th e toes • roxim al exten sion lesser troch an ter greater troch an ter

5

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

6

C

Ensure the e xte nsor te ndons are also prote cte d

Prote ct the tibial tube rosit and the pate lla

e t glove s m a e application of the se m irigid casting tape e asie r

rap the se mirigid casting tape around the fore foot

Pass diagonall ove r the he al and around the fore foot distall

Pass diagonall be ne ath the foot and ove r the Achille s te ndon

Pass ove r the he al and diagonall be ne ath the foot

Ensure the an le oint is in

Pass around the fore foot and diagonall down to wrap the an le

rap the le g using the half ove rlapping te chni ue

e xion

n

Appl e lastic foam tape to prote ct the bon promine nce s of the an le Ensure the re are no wrin le s in the tube bandage

e

Appl a tube bandage from the foot to the hip Pull the tube bandage tight to avoid an wrin le s

i

e

P

5 3

owe r e xtremit

a lf o ve rla pp ing

Ensure the re are no wrin le s ove r the ne e

rap at an angle from the gre ate r trochante r to the le sse r trochante r

Place the rst rigid splint m e diall , e xte nding ust past the ne e an assistant holds it in place distall

Place a se cond rigid splint late rall e nsure the ve ntral and dorsal side s re m ain ope n

Appl anothe r la e r of se m irigid casting tape from proxim al, to hold the splints in place , using the half ove rlapping te chni ue

Ensure the splints lie at ove r the sole of the foot

rap the an le using the gure of e ight te chni ue

Avoid too m an forward wraps, and e nsure e nough support and stabilit at the sole of the foot

Trim the tube bandage distall , and fold it bac ove r the se m irigid casting tape

old bac the tube bandage ove r the se m irigid casting tape proxim all

Subm e rge the se m irigid casting tape in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

e

n

i

e

6

ong le g cast using s nthe tic, combicast te chni ue

5 4

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Appl the we t bandage from proxim al to distal

Ensure the an le oint is in e xion m old the cast to the arch of the foot

Ensure the re are no wrin le s in the cast from dorsal ove r e xion of the an le

Tap the cast to m a e sure it has se t, and re m ove the we t bandage

re e m ove m e nt of the toe s, and capillar re ll

A cast shoe can e asil be worn

IN

SS SS

Kne e in e xion

n

Subm e rge an e lastic bandage in wate r using a we t bandage acce le rate s the se tting

e

rap the com ple te le g with a se cond la e r of se m irigid casting tape , from distal to proxim al

i

e

6

Klaus Dre sing, os Engele n

NT

e xion and the an le oint in

5 5

owe r e xtremit

C ST

Ensure the splitting line passe s dorsall to the m e dial m alle olus

se the scissors to cut com ple te l through the cast, from proxim al to distal

uide the scissors dorsall to the m e dial m alle olus

e

n

i

e

6

ong le g cast using s nthe tic, combicast te chni ue

old bac the cut se ction and ge ntl re m ove the cast

5 6

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

6

Sarmiento patella tendon bearing cast using plaster of Paris

IN IC TI N

• Stable diaph yseal fractu res of th e tibia lim ited to th e distal tw o th irds of th e tibial sh aft • rim ary u n stable tibial fractu res at th e h ard callu s form ation stage

• Stabilization of th e low er leg

IP

NT

Cast padding Plaste r of Paris splint 3

Plaste r of Paris rolls

4

Tube bandage

5

Cre pe pape r bandage

6

Cut tube bandage

cm or cm or

cm cm

cm in dispe nse r box

Scissors

P

S NN

1 5

owe r e xtremit

P SITI NIN

e

n

i

e

6

Sarmie nto pate lla te ndon bearing cast using plaste r of Paris

Place the patie nt supine or se ate d on a table Place the ne e in approxim ate l

e xion and the an le oint in

SP CI

T IN S T

e xion

P IN

IN

• Su pport at th e patella ten don an d th e tibial con dyles • ree m o em en t of th e kn ee join t • ree m o em en t of th e toes

5

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

6

C

e

P

i

Ensure the tube bandage e xte nds past the fe m oral cond le s

n

Pull the tube bandage tight to avoid an wrin le s, and trim distall

e

Appl a tube bandage from the foot to ove r the ne e

a lf o ve rla p p in g

Appl the padding ove r the tube bandage

rap the le g using the half ove rlapping te chni ue

Ensure the padding cove rs the e ntire pate lla

Appl a thic la e r of padding ove r the pate lla, and a thin la e r ove r the tibial tube rosit , to provide the corre ct support

Appl a pape r bandage to form a barrie r be twe e n the dr padding and the we t POP

rap the le g using the half ove rlapping te chni ue

Subm e rge a roll of POP in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Appl the roll of POP starting distall

5

owe r e xtremit

rap the le g using the half ove rlapping te chni ue

Appl e xtra la e rs of POP ove r the pate lla

Pre pare a POP splint to be applie d ve ntrall , and ove r the pate lla

e

n

i

e

6

Sarmie nto pate lla te ndon bearing cast using plaste r of Paris

Subm e rge the POP splint in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

old ove r the proxim al corne rs

old bac the tube bandage ove r the cast distall

5

Stretch and smooth out the splint, pressing the la ers together, resulting in a compact splint If this procedure is not done, puff pastr plaster will result, causing an unstable splint

Appl the POP splint ve ntrall

Mold the splint to the ne e

Appl a short POP splint across the tibial cond le s for e xtra support

Subm e rge a roll of POP in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Appl the roll of POP, from distal to proxim al, to x the tube bandage and the POP splint in place

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

e

6

Klaus Dre sing, os Engele n

Ensure the an le oint is in

Mar the cast whe re it should be trim m e d proxim all

Trim the cast with cast scissors or an oscillating saw

old bac the tube bandage and the padding ove r the cast to form a sm ooth e dge

Ensure fre e m ove m e nt of the ne e is possible

In e xte nsion, the support lie s ove r the pate lla and the pate lla te ndon

old bac the tube bandage to re ve al the padding

i

Afte r the cast has se t, trim it to allow fre e m ove m e nt of the ne e

e xion

Mold the POP splint to form two de nts at the tibial cond le s, m e dial and late ral of the tibial tube rosit

n

As the POP be gins to se t, it m ust be pe rfe ctl m olde d to the pate lla te ndon and the tibial cond le s

e

rap the le g using the half ove rlapping te chni ue

ate ral de nt is visible on the cast

5

owe r e xtremit

Appl we t strips of POP to x the padding to the cast

old bac the tube bandage ove r the cast

Appl a we t roll of POP to x the tube bandage to the cast

Ensure pe rfe ct m olding of the cast to the pate lla te ndon and the tibial cond le s has occurre d

The triangular shape allows control of rotation

e

n

i

e

6

Sarmie nto pate lla te ndon bearing cast using plaste r of Paris

Mold the cast to give a sm ooth nish proxim all

IN

SS SS

NT

The re is e xion and e xte nsion of the ne e and toe s

5

During weight bearing, the force is transmitted from the cond les to the cast to prote ct the fracture region from weight bearing

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

6

Sarmiento tibial brace using s nthetic, combicast techni ue

IN IC TI N

• Som e diaph yseal fractu res of th e tibia • ot recom m en ded for prim ary fractu re care

• Stabilization of th e tibia

IP

NT

e lcro strips nonadhe sive hoo e lcro strips adhe sive loop 3

igid s nthe tic splint

4 Se mirigid casting tape

cm x

cm

cm

5 Cut tube bandage 6 Tube bandage

cm in dispe nse r box

Scissors love s Elastic bandage Elastic foam tape

P

S NN

1 5 3

owe r e xtremit

P SITI NIN

e

n

i

e

6

Sarmie nto tibial brace using s nthe tic, com bicast te chni ue

Place the patie nt supine or se ate d on a table Place the ne e in approxim ate l

e xion and the an le oint in

SP CI

T IN S T

e xion

P IN

IN

• Th e castin g m aterial is applied circu larly after it is split it w ill be reapplied an d u sed as a brace xed w ith elcro straps • Th e brace m u st be tigh t en ou gh to obtain th e com pression effect • ree m o em en t of th e kn ee an d an kle join t • u n ction al treatm en t

5 4

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

6

C

Inse rt a se cond tube bandage unde r the rst on the dorsal side it will be use d late r to m a e splitting the brace e asie r

Appl e lastic foam tape to prote ct the bon prom ine nce s

Place the rst strip of e lastic foam tape from the late ral malle olus to the m e dial m alle olus

Appl e lastic foam tape ove r the tibial tube rosit and the bular he ad

n

On the ve ntral side , a rigid splint will be applie d to give support e lse whe re , se m irigid m ate rial will be use d

e

Appl a tube bandage from the foot to ove r the ne e

i

e

P

a lf ove rla p p in g

Appl se m irigid casting tape from distal to proxim al be gin with circular wraps, the n use the half ove rlapping te chni ue

Appl the se m irigid casting tape ove r the e lastic foam tape it will be trim m e d late r

The le g hangs fre e during this proce dure

Appl a rigid splint on the ve ntral side for e xtra support old the rigid splint in half and fan out the proxim al e nd

5 5

owe r e xtremit

6

Sarmie nto tibial brace using s nthe tic, com bicast te chni ue

Appl a se cond la e r of se m irigid casting tape proxim all

Appl the se mirigid casting tape distall to cove r the rigid splint, and m old it to the malle oli

Subm e rge the e lastic bandage in wate r using a we t bandage acce le rate s the se tting

Appl the we t bandage , from distal to proxim al, using the half ove rlapping te chni ue

old the an le in dorsi e xion, and m old the brace to the tibia

old the brace in the de sire d position until it is se t

he n the brace has se t, place the le g in the hori ontal position, and re m ove the we t bandage

Prepare the brace for trimming mar the distal tibia, the lateral malleolus, and the medial malleolus Connect these points to mar the distal trimming line

The proximal borde r of the brace is from the tibial tube rosit to cm be low the bular he ad, to allow fre e m ove m e nt of the ne e

Cut through the folde d ove r tube bandage proxim all

e

n

i

e

Trim the rigid splint distall to avoid pre ssure on the e xte nsor te ndons

old the inner tube bandage bac , from proximal to distal, and wrap with semirigid casting tape This procedure will allow the brace to be close d with an overlapping edge

5 6

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

e

6

Klaus Dre sing, os Engele n

The ap is ope ne d and the tube bandage and the lowe r la e r are cut through, contralate rall to the rst cut

owe r the le g and re m ove the brace

i

This ap will be use d as an ove rlap whe n the brace is close d

n

Trim the tube bandage distall , fold bac the split la e r, and re m ove the oute r se ction of the tube bandage

e

Slide one blade of the scissors into the oute r tube bandage and split ope n the oute r la e r of se m irigid casting tape

Trim the brace along the mar e d e dge s with the scissors

The shape of the late ral m alle olus and the m e dial m alle olus are visible in the brace

Trim the proxim al e dge of the brace

The e lastic foam tape is cut through the ve ntral and dorsal he ight diffe re nce is cle ar

Appl a ne w tube bandage , or a long soc , to pre ve nt an irritation of the s in

e appl the brace Distall , the support lie s dire ctl ove r the late ral m alle olus and the m e dial m alle olus

Ensure fre e m ove m e nt of the an le oint is possible

5

owe r e xtremit

Appl four short strips of adhe sive ve lcro with hoo s to the brace

Attach a long strip of ve lcro with loops to the short ve lcro, pass around the le g, tighte n, and close the brace Trim an e xce ss ve lcro b ma ing two cuts

Alte rnate the dire ction of the ve lcro strips to avoid an rotation of the brace

e

n

i

e

6

Sarmie nto tibial brace using s nthe tic, com bicast te chni ue

IN

SS SS

NT

The brace is close d on the dorsal side

re e m ove m e nt of the ne e

5

re e e xion and e xte nsion of the an le oint

Due to closure with ve lcro, the brace doe s not slip

old ove r the tube bandage , distall and proxim all , to prote ct the s in

If the brace be com e s loose , the ve lcro strips allow e as re tighte ning

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

6

Dorsal short leg splint using plaster of Paris

IN IC TI N

• • •

ractu re of th e an kle ractu re of th e tarsal bon es igam en tou s ru ptu res

• Stabilization of th e an kle join t an d foot

IP

NT

Cast padding Plaste r of Paris splint 3 Plaste r of Paris splint 4 Tube bandage

cm or

cm

cm

cm in dispe nse r box

5 Cre pe pape r bandage 6 Elastic bandage au e bandage Cut tube bandage Scissors Surgical tape or bandage clips

P

S NN

1 5

owe r e xtremit Dorsal short le g splint using plaster of Paris

e

n

i

e

6

P SITI NIN

Place the patie nt prone whe ne ve r possible or supine on a table Place the affe cte d le g on a support, with the an le oint in

SP CI

T IN S T

e xion

P IN

IN

• En su re th e bu la h ead rem ain s free a m in im u m of to a oid pressu re on th e peron eal n er e • ree exion of th e kn ee • h en possible free m o em en t of th e toes

5

cm

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

C

rap the le g using the half ove rlapping te chni ue

Appl a pape r bandage to form a barrie r be twe e n the dr padding and the we t POP

rap the le g using the half ove rlapping te chni ue

Pre pare the poste rior POP splint

Subm e rge the POP splint in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Stre tch and smooth out the splint, pre ssing the la ers toge the r, re sulting in a compact splint If this proce dure is not done, puff pastr plaster will re sult, causing an unstable splint

Appl the the foot

Trim the splint proximall , and m old it to the le g

n

Appl the padding ove r the tube bandage , from distal to proxim al

e

Appl a tube bandage from the foot to ove r the ne e

i

e

6

P

a lf o ve rla pp ing

shape d POP splint, starting at

Pre pare a

shape d POP splint

5

owe r e xtremit

e

n

i

e

6

Dorsal short le g splint using plaster of Paris

5

Subm e rge the POP splint in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Appl the shaped POP splint under the heel, and mediall and laterall along the lower leg Mold the splint from distal to proximal

rap the splint with a gau e bandage , be ginning distall

rap the le g using the half ove rlapping te chni ue

Mold the com ple te splint to the de sire d shape

old the an le oint in se tting

Tap on the splint to che c it has se t

Afte r the splint has se t, turn the patie nt from the prone to the supine position

old bac the tube bandage ove r the splint, proxim all and distall

Trim the e xce ss tube bandage

Mar the splitting line

Split the com ple te splint, including the tube bandage , with the scissors

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

e xion while

Klaus Dre sing, Pe te r Trafton

e

6

Klaus Dre sing, os Engele n

i

Se cure the bandage with surgical tape or bandage clips

n

rap the le g using the half ove rlapping te chni ue

e

rap the splint with an e lastic bandage , from distal to proxim al

IN

SS SS

NT

re e e xion of the ne e

re e m ove m e nt of the toe s

5 3

owe r e xtremit

e

n

i

e

6

Dorsal short le g splint using plaster of Paris

5 4

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

6

Dorsal short leg splint using s nthetic

IN IC TI N

• • •

ractu re of th e an kle ractu re of th e tarsal bon es igam en tou s ru ptu res

• Stabilization of th e an kle join t an d foot

IP

NT

Cast padding igid s nthe tic splint or cm x cm

cm

3 Cut tube bandage 4 Tube bandage

cm in dispe nse r box

5 Elastic bandage 6

au e bandage Scissors love s Elastic bandage Surgical tape or bandage clips

P

S NN

1 5 5

owe r e xtremit Dorsal short le g splint using s nthe tic

e

n

i

e

6

P SITI NIN

Place the patie nt supine or prone on a table Place the affe cte d le g on a support, with the an le oint in

SP CI

T IN S T

e xion

P IN

IN

• En su re th e bu la h ead rem ain s free a m in im u m of cm to a oid pressu re on th e peron eal n er e • ree exion of th e kn ee • h en possible free m o em en t of th e toes

5 6

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

C

e

6

P

i

Appl the padding, from distal to proximal

n

Place the ne e on a support pull the tube bandage ove r the ne e and pull it tight to avoid an wrin le s

e

Appl a tube bandage ove r the foot and an le

a lf ove rla p p in g

rap the le g using the half ove rlapping te chni ue

Pre pare two splint

shape d splints and a footplate

e m ove one la e r of splint and fold in thre e to ma e the footplate splint

Trim the splint to t the foot

Shape the splint li e this

Se parate the re m aining splint la e rs in two to ma e the shape d splints

Place the rst splint be ne ath the foot, and at e ual le ngth along both side s of the le g

or patie nts with longe r le gs, place m ore of the splint on one side of the le g than the othe r

5

owe r e xtremit

Place a se cond splint on the othe r side of the le g

e

n

i

e

6

Dorsal short le g splint using s nthe tic

If an assistant is available , the hold the rst shape d splint in place while the footplate splint is applie d

Appl the se cond rst

shape d splint ove r the

Ensure the an le oint is in e xion appl the gau e bandage starting distall

5

Subm e rge the rigid splint in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

old up the distal e nd of the tube bandage

If ou are wor ing alone , appl the rst shape d splint and fold the e nds ove r e ach othe r

Appl the we t footplate splint fan out the splint ove r the he e l to pre ve nt a thic e dge form ing, and m old to the sole of the foot

e m ove a se ction of the splints ove r the dorsal distal tibia with the scissors

Subm e rge a gau e bandage in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

As the gau e bandage is applie d, m old the splint to the foot and le g

rap the le g using the half ove rlapping te chni ue

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Trim the footplate splint to m atch the shape of the toe s

Mold the footplate splint to m atch the contours of the foot

he n wor ing on the right le g, appl the ball of the le ft thum b to the arch of the foot to m old the splint

old the foot in the de sire d position until the splint is se t

Tap on the splint to che c it has se t old bac the tube bandage ove r the splint, distall and proxim all

Split the splint com ple te l , using the ste p b ste p splitting and xing te chni ue

e gin the splitting distall , cutting through all la e rs

Cut through anothe r se ction of the splint

rap the le g using the half ove rlapping te chni ue

n

Appl a se cond la e r of we t gau e bandage , be ginning proximall

e

Mold the com ple te splint to the de sire d shape

i

e

6

Klaus Dre sing, os Engele n

ix the cut se ction with an e lastic bandage

5

owe r e xtremit

e

n

i

e

6

Dorsal short le g splint using s nthe tic

Split and x the re st of the splint using the splitting and xing te chni ue avoids loss of re duction

IN

SS SS

Se cure the bandage with surgical tape or bandage clips

NT

Exte nsion and e xion of the toe s is possible

In the dorsal aspe ct, the splint is shape d and m olde d to the sole of the foot and cove rs the toe s

In the frontal aspe ct, the splint is

shape d

The splint stops two nge r s bre adth be low the bula he ad

In the late ral aspe ct, the an le oint is at

The splint is form e d to the sole of the foot and the le g

The splint allows fre e m ove m e nt of the toe s

53

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

6

Short leg cast using rigid s nthetic

IN IC TI N

Secon dary treatm en t o : • Fractu re o th e distal tibia • Fractu re o th e an kle • Fractu re o th e oot

• Stabilization o th e distal tibia, th e an kle, an d th e oot

IP

NT

Cast padding igid casting tape 3

Cut tube bandage

4

Tube bandage

5

Scissors

6

love s

cm or

cm

cm in dispe nse r box

Oscillating saw Elastic bandage

P

S NN

1 53

owe r e xtremit Short le g cast using rigid s nthe tic

e

n

i

e

6

P SITI NIN

Place the patie nt supine on a table Place the ne e on a support in e xion

e xion and the an le oint in

SP CI

T IN S T

P IN

IN

• En su re th e bu la h ead rem ain s ree a m in im u m o 2 cm to avoid pressu re on th e peron eal n erve • Free f exion o th e kn ee • Free exten sion , an d i possible, f exion o th e toes • Pressu re sores

53

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

C

e

6

P

Appl a tube bandage from the foot to the ne e

Tie a not in the tube bandage and place the not be twe e n the rst and se cond toe s to avoid e xce ss com pre ssion across the toe s

Position the an le oint in

Ensure the foot is positione d halfwa be twe e n supination and pronation

Appl the padding wrap the padding past the e nd of the toe s to provide e xtra prote ction

rap the le g using the half ove rlapping te chni ue

Exte nd the padding highe r than the nal he ight of the cast whe n it is folde d ove r, the re is a soft e dge to the cast

Subm e rge a roll of rigid casting tape in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

rap the an le using the gure of e ight te chni ue

rap the le g using the half ove rlapping te chni ue

e

n

i

e xion

a lf ove rla p p in g

Appl the rigid casting tape wrap the e nds of the toe s thre e tim e s, without appl ing an com pre ssion

533

owe r e xtremit

a lf o ve rla pp ing

old bac the tube bandage and the padding ove r the rigid casting tape proxim all

Appl anothe r la e r of we t rigid casting tape , starting proximall

Mold the cast to the contours of the foot

Pull out the tube bandage from be twe e n the toe s to re le ase pre ssure and allow m ove m e nt of the toe s

old the foot and an le in the de sire d position until the cast is se t

e m ove part of the cast ove r the toe s, cut down to the base of the big toe

Cut across to the base of the little toe

Cut be low the le ve l of the little toe to e nsure it is com ple te l fre e at the dorsal aspe ct to allow fre e m ove m e nt

Trim the base of the cast to match the shape of the foot

Ensure the cast is ope n from the base of the big toe to the base of the little toe

e

n

i

e

6

Short le g cast using rigid s nthe tic

534

e m ove the padding from ove r the toe s

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Tuc the padding unde r the tube bandage and cut off the e xce ss

old bac the tube bandage ove r the cast, and trim

Appl anothe r la e r of we t rigid casting tape ove r the tube bandage

Appl longitudinal plantar xation of the fore foot to nish the cast

Subm e rge an e lastic bandage in wate r using a we t bandage acce le rate s the se tting

Appl the we t e lastic bandage around the foot

n

Appl additional la e rs of padding be ne ath the toe s for e xtra prote ction and com fort

e

old bac the tube bandage to che c that all the toe s are fre e

i

e

6

Klaus Dre sing, os Engele n

old the foot and an le in the de sire d position during se tting

Afte r the cast has se t, re m ove the we t bandage

535

owe r e xtremit Short le g cast using rigid s nthe tic

SS SS

NT

All toe s are fre e and have a full e xte nsion

le xion and e xte nsion of the ne e is possible and the an le oint is in

e xion

If we ight be aring is allowe d, the use of a cast shoe is m andator

e

n

i

e

6

IN

C ST

Mar the splitting line s avoid the late ral and the m e dial m alle olus

The saw blade oscillate s and doe s not rotate , so the re is no dire ct harm to the s in

Split the cast with the oscillating saw be gin on the m e dial side

To re m ove the ante rior se ction of the cast, cut ust above the m e dial m alle olus and ust be low the late ral m alle olus

Turn the le g and split the late ral side of the cast

Cut through the padding and the tube bandage on both side s of the cast using scissors

e m ove both se ctions of the cast

536

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

6

3

Short leg cast using s nthetic, combicast techni ue

IN IC TI N

Secon dary treatm en t o : • Fractu re o th e distal tibia • Fractu re o th e an kle • Fractu re o th e oot

• Stabilization o th e distal tibia, th e an kle, an d th e oot

IP

NT

Semirigid casting tape

cm

Elastic foam tape 3

igid s nthe tic splint

4

Cut tube bandage

5

Tube bandage

6

Scissors

cm x

cm

cm in dispe nse r box

love s Elastic bandage Surgical tape or bandage clips

P

S NN

1 53

owe r e xtremit

P SITI NIN

e

n

i

e

6

3

Short le g cast using s nthe tic, combicast te chni ue

Place the patie nt supine on a table Place the ne e on a support in e xion

e xion and the an le oint in

SP CI

T IN S T

P IN

IN

• En su re th e bu la h ead rem ain s ree a m in im u m o 2 cm to avoid pressu re on th e peron eal n erve • Free f exion o th e kn ee • Free exten sion , an d i possible, f exion o th e toes • Pressu re sores

53

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

C

The e xte nsor te ndons should also be prote cte d

The tibial cre st should also be prote cte d

Subm e rge the se m irigid casting tape in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Appl the se m irigid casting tape around the fore foot, le aving the toe s fre e

rap diagonall ove r the an le , to the m e dial m alle olus, and across the Achille s te ndon

Pass diagonall be ne ath the foot

Pass ove r the late ral malle olus, the an le oint, the Achille s te ndon, and diagonall be ne ath the foot

n

Appl e lastic foam tape to prote ct the bon promine nce s the late ral m alle olus and the m e dial m alle olus

e

Appl a tube bandage from the foot to the ne e Pull the tube bandage tight to avoid an wrin le s

i

e

6

P

3

Klaus Dre sing, os Engele n

a lf o ve rla p p in g

Support the late ral side of the foot

rap the le g using the half ove rlapping te chni ue

53

owe r e xtremit

6

3

Short le g cast using s nthe tic, combicast te chni ue

old bac the tube bandage ove r the se m irigid casting tape , proxim all and distall , and trim it

Appl anothe r la e r of we t se mirigid casting tape ove r the rigid splint

Ensure the rigid splint doe s not cove r the ve ntral side of the le g

rap the an le using the gure of e ight te chni ue

rap the distal e dge of the cast, late ral to m e dial, to avoid supination

Subm e rge an e lastic bandage in wate r using a we t bandage acce le rate s the se tting

rap the com ple te cast with the e lastic bandage

Mold the cast to the de sire d position

Tap on the cast to che c it has se t, and re m ove the we t bandage

e

n

i

e

old bac the tube bandage proximall to hold the roll of se m irigid casting tape in place

Appl a shape d rigid splint be ne ath the foot, and m e diall and late rall along the lowe r le g old the rigid splint in place with se m irigid casting tape

54

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

SS SS

NT

e

6

IN

3

Klaus Dre sing, os Engele n

i

A cast shoe can be worn

n

nhinde re d e xion and e xte nsion of the ne e is possible

e

re e m ove m e nt of the toe s

C ST SP ITTIN

I

I

Place the patie nt in the prone position

At the bac of the le g is the soft are a of the cast

Mar the splitting line

Slide one blade of the scissors unde r all the la e rs and split the cast

Cut the cast around the he e l

Place the patie nt in the supine position to re m ove the cast

Corre ct splitting of the cast allows e asie r re application

or e asie r re application of the cast, a tube bandage or a long soc is applie d

Pull the e nd of the tube bandage it will be use d as an aid to m ount the cast

54

owe r e xtremit

Slide the cast ove r the tube bandage , using the e xce ss to counte r the force applie d

Spre ad the cast to t around the le g

Trim the tube bandage distall , and fold it bac ove r the cast

Appl an e lastic bandage to close the cast

rap the an le using the gure of e ight te chni ue

rap the le g using the half ove rlapping te chni ue

e

n

i

e

6

3

Short le g cast using s nthe tic, combicast te chni ue

Se cure the bandage with surgical tape or bandage clips

IN

SS SS

NT C ST SP ITTIN

re e m ove m e nt of the toe s

54

le xion and e xte nsion of the ne e is possible and the an le oint is in e xion

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

6

4

Antirotation short leg cast using s nthetic, combicast techni ue

IN IC TI N

• Trau m atic h ip dislocation • ip dislocation after arth roplasty

• To pre en t rotation of th e leg

IP

NT

igid s nthe tic splint

cm x

cm

cm x

cm

Elastic foam tape 3

igid s nthe tic splint

4 Cut tube bandage 5

roomstic

6 Tube bandage

cm in dispe nse r box

Se mirigid casting tape

cm

Scissors love s Elastic bandage

P

S NN

1 543

owe r e xtremit

P SITI NIN

e

n

i

e

6

4

Antirotation short le g cast using s nthe tic, combicast te chni ue

Place the patie nt supine on a table Place the ne e on a support in e xion

e xion, and the an le oint in

SP CI

T IN S T

P IN

IN

• En su re th e bu la h ead rem ain s free a m in im u m of cm to a oid pressu re on th e peron eal n er e • ree exion of th e kn ee • ree exion an d exten sion of th e toes • ressu re sores • o distu rban ce of th e con tralateral leg

544

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

C

Appl e lastic foam tape to prote ct the bon promine nce s the late ral m alle olus and the m e dial m alle olus

The e xte nsor te ndons are also prote cte d

The tibial cre st should be prote cte d

Subm e rge the se m irigid casting tape in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Appl the se m irigid casting tape around the fore foot, le aving the toe s fre e

rap diagonall ove r the an le , to the m e dial m alle olus, and across the Achille s te ndon

Pass diagonall be ne ath the foot

Pass ove r the late ral malle olus, the an le oint, the Achille s te ndon, and diagonall be ne ath the foot

e

n

Appl a tube bandage from the foot to the ne e Pull the tube bandage tight to avoid an wrin le s

i

e

6

P

4

Klaus Dre sing, os Engele n

a lf o ve rla p p in g

Support the late ral side of the foot

rap the le g using the half ove rlapping te chni ue

545

owe r e xtremit

6

4

Antirotation short le g cast using s nthe tic, combicast te chni ue

old bac the tube bandage ove r the se m irigid casting tape , proxim all and distall , and trim it

Appl anothe r la e r of we t se mirigid casting tape ove r the rigid splint

Ensure the rigid splint doe s not cove r the ve ntral side of the le g

rap the an le using the gure of e ight te chni ue

rap the distal e dge of the cast, late ral to m e dial, to avoid supination

Subm e rge an e lastic bandage in wate r using a we t bandage acce le rate s the se tting

rap the com ple te cast with the e lastic bandage

Mold the cast to the de sire d position

Tap on the cast to che c it has se t, and re m ove the we t bandage

Place a broom stic or woode n rod be ne ath the le g to pre ve nt an e xorotation or e ndorotation

e

n

i

e

old bac the tube bandage proximall to hold the roll of se m irigid casting tape in place

Appl a shape d rigid splint be neath the foot, and me diall and late rall along the lower le g old the rigid splint in place with semirigid casting tape

546

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Subm e rge a roll of se mirigid casting tape in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Place the rigid splint on the cast ove r the Achille s te ndon, and wrap with se m irigid casting tape

Place the broom stic ove r the rigid splint, and attach to the le g with se m irigid casting tape using the gure of e ight te chni ue

Com ple te l wrap the broom stic with se m irigid casting tape

Subm e rge an e lastic bandage in wate r using a we t bandage acce le rate s the se tting

rap the we t bandage around the we t se m irigid casting tape and the broom stic

e m ove the we t bandage afte r the cast has se t

n

Subm e rge the rigid splint in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

e

Pre pare the short rigid splint to be place d be twe e n the cast and the broom stic

i

e

6

4

Klaus Dre sing, os Engele n

54

owe r e xtremit

PIN C

SS SS

NT

No rotation of the le g is possible

re e m ove m e nt of the contralate ral le g is possible

e

n

i

e

6

4

Antirotation short le g cast using s nthe tic, combicast te chni ue

54

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

6

5

emovable an le splint using s nthetic, combicast techni ue

IN IC TI N

• • • • •

ostoperati e protection after an kle osteosyn th esis on displaced an kle fractu res igam en tou s ru ptu res An kle sprain ractu re of th e proxim al fth m etatarsal

• Stabilization of th e an kle join t

IP

NT

e lcro strips adhe sive loop e lcro strips nonadhe sive hoo 3 Adhe sive foam padding 4 Cut tube bandage 5 Tube bandage

cm in dispe nse r box

6 Se mirigid casting tape igid casting tape

cm

cm

Scissors love s Elastic bandage

P

S NN

1 54

owe r e xtremit

P SITI NIN

e

n

i

e

6

5

emovable an le splint using s nthe tic, combicast te chni ue

Place the patie nt supine or se ate d on a table Place the ne e on a support, and the an le oint in

SP CI

e xion

T IN S T

P IN

IN

• Bon y prom in en ces • En su re soft edges of th e splin t

55

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

C

Place thre e la e rs of rigid casting tape on the adhe sive surface of the foam padding

Appl the foam padding around the base of the foot and ove r the an le e nsure the rigid casting tape face s outward

The patie nt holds the foam padding in place e nsure the rigid casting tape lie s ove r the late ral malle olus and the m e dial m alle olus

Subm e rge the se m irigid casting tape in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Appl the se m irigid casting tape around the an le and the base of the foot

Ensure the se m irigid casting tape is not wrappe d too far distall

rap the le g using the half ove rlapping te chni ue

Ensure the an le oint is in

Exte nd the se m irigid casting tape a m inim um of a handbre adth above the m alle oli

n

Cut the re uire d le ngth of adhe sive foam padding and re m ove the prote ctive pape r la e r

e

Appl a tube bandage ove r the foot and an le Pull the tube bandage tight to avoid an wrin le s

i

e

6

P

5

Klaus Dre sing, os Engele n

a lf ove rla p p in g

e xion

55

owe r e xtremit

e

n

i

e

6

5

emovable an le splint using s nthe tic, combicast te chni ue

55

Attach thre e short strips of adhe sive ve lcro with loops to the dorsal surface of the splint

Subm e rge an e lastic bandage in wate r using a we t bandage acce le rate s the se tting

Ensure the an le oint is in during se tting

Afte r the splint has se t, re m ove the we t bandage

Mar the splint for trim m ing

Split the splint on the ve ntral side e nsure fre e m ove m e nt of the an le oint

e ave e nough of the splint to support the foot

Ensure the calcane us is fre e up to the inse rtion of the Achille s te ndon

Split the splint on the ve ntral side , from proxim al to distal, using the scissors

Ope n the splint and re m ove it

Trim the splint to the de sire d shape

Ensure that e nough splint is re m ove d on the m e dial side to allow fre e m ove m e nt

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

e xion

Klaus Dre sing, Pe te r Trafton

Ensure the re is no pre ssure ove r the Achille s te ndon

The padding give s m ore com fort for the patie nt

The shape of the late ral side of the foot can be se e n in the splint

The splint can be worn ove r a soc

Attach thre e strips of ve lcro with hoo s to close the splint

The splint supports the late ral e dge of the foot against supination

The patie nt can we ar a norm al shoe , pre fe rabl a lace up or ve lcro shoe

n

The he e l must be com ple te l fre e

e

The splint supports the late ral side of the foot to pre ve nt supination

i

e

6

5

Klaus Dre sing, os Engele n

553

owe r e xtremit

PIN C

SS SS

NT

re e e xion and e xte nsion of the an le oint

The splint has no sharp e dge s

e

n

i

e

6

5

emovable an le splint using s nthe tic, combicast te chni ue

554

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

6

6

ifth metatarsal cast using s nthetic, combicast techni ue

IN IC TI N

•

ractu re of th e proxim al fth m etatarsal • ractu re of th e an kle type eber A • A u lsion fractu re of th e m edial m alleolu s

• Stabilization of th e an kle join t an d th e tarsu s

IP

NT

Cast shoe igid s nthe tic splint

cm x

3

Semirigid casting tape

cm

4

Cut tube bandage

5

Tube bandage

6

Elastic foam tape

cm

cm in dispe nse r box

Scissors love s Elastic bandage

P

S NN

1 555

owe r e xtremit

P SITI NIN

e

n

i

e

6

6

ifth me tatarsal cast using s nthe tic, combicast te chni ue

Place the patie nt supine or se ate d on a table Place the ne e on a support, and the an le oint in

SP CI

e xion

T IN S T

P IN

IN

• addin g of th e m alleoli • u n ction al position of th e an kle • alfw ay betw een su pin ation an d pron ation • In case of se ere sw ellin g th e cast sh ou ld be split

556

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

C

Appl the rst la e r of se m irigid casting tape , be ginning at the le ve l of the sm all toe , with a circular wrap

Pass the se m irigid casting tape ove r the he e l e nsure the an le oint is in e xion

Continue b using the gure of e ight te chni ue ove r the Achille s te ndon and diagonall be ne ath the foot

Pass once m ore ove r the Achille s te ndon and diagonall be ne ath the foot

n

Appl e lastic foam tape to prote ct the late ral m alle olus, the m e dial m alle olus, and the inste p of the foot

e

Appl a tube bandage ove r the foot and an le Pull the tube bandage tight to avoid an wrin le s

i

e

6

P

6

Klaus Dre sing, os Engele n

a lf ove rla p p in g

Pass diagonall ove r the foot and wrap the distal tibia using the half ove rlapping te chni ue

Cut the se m irigid casting tape proxim all , and fold bac the tube bandage

Trim the tube bandage distall , and fold bac ove r the se m irigid casting tape

an out the la e rs of the rigid splint at one e nd

Shape the splint li e this

55

owe r e xtremit

The splint should be applie d ove r the fth m e tatarsal and late rall ove r the foot

Subm e rge the splint in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Appl the we t splint the la e rs of the splint should be fanne d out

Subm e rge the se m irigid casting tape in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Appl the se m irigid casting tape be gin proxim all with a circular wrap

Pass ove r the Achille s te ndon, and wrap diagonall be ne ath the foot

Appl a circular wrap distall , and pass diagonall ove r the he e l

Ensure the an le oint is in dorsi e xion while appl ing the last wraps

Subm e rge an e lastic bandage in wate r using a we t bandage acce le rate s the se tting

Appl the we t bandage using the sam e te chni ue as with the se m irigid casting tape

Mold the cast and hold in position until it is se t

Afte r the cast has se t, re m ove the we t bandage

e

n

i

e

6

6

ifth me tatarsal cast using s nthe tic, combicast te chni ue

55

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

SS SS

NT

e

6

IN

6

Klaus Dre sing, os Engele n

i

The patie nt can also we ar a norm al shoe , pre fe rabl a lace up or ve lcro shoe

n

A cast shoe can be worn during we ight be aring

e

The an le oint is in e xion The cast has sm ooth e dge s, and the re is fre e m ove m e nt of the toe s

55

owe r e xtremit

e

n

i

e

6

6

ifth me tatarsal cast using s nthe tic, combicast te chni ue

56

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

6

emovable fth metatarsal cast using s nthetic, combicast techni ue

IN IC TI N

•

ractu re of th e proxim al fth m etatarsal • ractu re of th e an kle type eber A • A u lsion fractu re of th e m edial m alleolu s

• Stabilization of th e an kle join t an d th e tarsu s

IP

NT

e lcro strips nonadhe sive hoo e lcro strips adhe sive loop 3

igid s nthe tic splint

cm x

cm

4 Cut tube bandage 5 Tube bandage

cm in dispe nse r box

6 Elastic foam tape Se mirigid casting tape

cm

Scissors love s Elastic bandage

P

S NN

1 56

owe r e xtremit e movable fth me tatarsal cast using s nthe tic, combicast te chni ue

e

n

i

e

6

P SITI NIN

Place the patie nt supine or se ate d on a table Place the ne e on a support, and the an le oint in

SP CI

e xion

T IN S T

P IN

IN

• addin g of th e m alleoli • u n ction al position of th e an kle • alfw ay betw een su pin ation an d pron ation • In case of se ere sw ellin g th e cast sh ou ld be split • Th e patien t can w ear th eir ow n sock u n der th e cast

56

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

C

Appl the rst la e r of se m irigid casting tape , be ginning at the le ve l of the sm all toe , with a circular wrap

Pass the se m irigid casting tape ove r the he e l e nsure the an le oint is in e xion

Continue b using the gure of e ight te chni ue ove r the Achille s te ndon and diagonall be ne ath the foot

Pass once m ore ove r the Achille s te ndon and diagonall be ne ath the foot

n

Appl e lastic foam tape to prote ct the late ral m alle olus, the m e dial m alle olus, and the inste p of the foot

e

Appl a tube bandage ove r the foot and an le Pull the tube bandage tight to avoid an wrin le s

i

e

6

P

a lf ove rla p p in g

Pass diagonall ove r the foot and wrap the distal tibia using the half ove rlapping te chni ue

Cut the se m irigid casting tape proxim all , and fold bac the tube bandage

Trim the tube bandage distall , and fold bac ove r the se m irigid casting tape

an out the la e rs of the rigid splint at one e nd

Shape the splint li e this

563

owe r e xtremit

The splint should be applie d ove r the fth m e tatarsal and late rall ove r the foot

Subm e rge the splint in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Appl the we t splint the la e rs of the splint should be fanne d out

Subm e rge the se m irigid casting tape in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Appl the se m irigid casting tape be gin proxim all with a circular wrap

Pass ove r the Achille s te ndon, and wrap diagonall be ne ath the foot

Appl a circular wrap distall , and pass diagonall ove r the he e l

Ensure the an le oint is in dorsi e xion while appl ing the last wraps

Subm e rge an e lastic bandage in wate r using a we t bandage acce le rate s the se tting

Appl the we t bandage using the sam e te chni ue as with the se m irigid casting tape

Mold the cast and hold in position until it is se t

Afte r the cast has se t, re m ove the we t bandage

e

n

i

e

6

e movable fth me tatarsal cast using s nthe tic, combicast te chni ue

564

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

S ue e e the cast toge the r be fore splitting to cre ate m ore space to inse rt the scissors

Split the cast, ope n the ap, and re m ove the cast

Place the patie nt in the supine position to re appl the cast

Attach two adhe sive ve lcro strips with loops to the ve ntral aspe ct of the cast

e appl the cast patie nts should we ar the ir own soc

Attach two long ve lcro strips with hoo s to close the cast A cast shoe or a normal lace up shoe can be worn

n

Mar the splitting line along the Achille s te ndon and ove r the hindfoot

e

Place the patie nt in the prone position be fore splitting the cast

i

e

6

Klaus Dre sing, os Engele n

565

owe r e xtremit e movable fth me tatarsal cast using s nthe tic, combicast te chni ue

SS SS

NT

e

n

i

e

6

IN

566

The an le oint is in e xion The cast has sm ooth e dge s, and the re is fre e m ove m e nt of the toe s A cast shoe or a lace up or ve lcro shoe can be worn

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

6

oot cast using s nthetic, combicast techni ue

IN IC TI N

• • •

ractu re of th e m etatarsals ractu re of tarsals ostoperati e treatm en t after osteosyn th esis of tarsals an d m etatarsals

• Stabilization of h in dfoot m idfoot an d forefoot

IP

NT

Cast shoe igid s nthe tic splint 3

Cut tube bandage s

4

Tube bandage

5

Cast padding

6

Semirigid casting tape

cm x

cm

cm in dispe nse r box cm

Scissors love s Elastic bandage

P

S NN

1 56

owe r e xtremit oot cast using s nthe tic, combicast te chni ue

e

n

i

e

6

P SITI NIN

Place the patie nt supine on a table Place the ne e on a support, and e nsure fre e m ove m e nt of the toe s

SP CI

T IN S T

P IN

IN

• ree m o em en t of th e an kle join t • En su re free m o em en t of th e toes by open in g th e dorsal aspect of th e cast

56

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

C

Padding e nsure s the re is e nough space in the foot cast to allow the patie nt to wal without discom fort

Padding holds the toe s apart

old ve or six la e rs of additional padding and appl ove r the e nd of the toe s

Inse rt the padding into a tube bandage to cre ate a roll of padding for the toe s

Ma e a not at one e nd of a se cond tube bandage the not will be place d ove r the rst and se cond toe

Appl the tube bandage to above the an le e nsure the padding re m ains in the de sire d position

Appl additional padding to prote ct the e xte nsor te ndons

Appl te nsion to the not and place it be twe e n the rst and se cond toe

Pre pare the footplate using a la e r rigid splint old the splint to ma e a la e r splint to match the le ngth and width of the foot

an out the splint and trim both e nds

e

n

Appl a small folde d pie ce of padding be twe e n e ach toe

i

e

6

P

Shape the splint li e this

56

owe r e xtremit

sing we t glove s m a e s it e asie r to appl the se m irigid casting tape

Appl two la e rs of se m irigid casting tape longitudinall hold it in place with circular wraps

Subm e rge the rigid splint in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Appl the footplate splint hold in place with a la e r of se m irigid casting tape

Subm e rge an e lastic bandage in wate r using a we t bandage acce le rate s the se tting

Appl the we t bandage using the sam e te chni ue as with the se m irigid casting tape

Mold the arch of the foot using the ball of the thum b do not dorsi e x the toe s

Provide plantar support unde r the toe s and m e tatarsal he ads

If a at sole is ne e de d for the cast, hold a at surface against it

e m ove the we t bandage afte r the cast has se t Ensure the cast has be e n m olde d to the arch of the foot

Trim the cast to allow fre e m ove m e nt of the toe s and an le

e m ove the ne e support be fore trim m ing the cast

e

n

i

e

6

oot cast using s nthe tic, combicast te chni ue

5

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

e

6

Klaus Dre sing, os Engele n

Split the cast down to the base of the rst m e tatarsal and re m ove the padding tube

i

Inse rt the scissors and split the cast late rall to the base of the fth m e tatarsal

e m ove the dorsal distal se ction of the cast to fre e the toe s be gin b m a ing a sm all hole ove r the padding

n

Ensure fre e m ove m e nt of the an le oint is possible

e

Trim the cast be low the m e dial m alle olus and the late ral malle olus

e m ove the padding be twe e n the toe s

5

owe r e xtremit oot cast using s nthe tic, combicast te chni ue

SS SS

NT

re e m ove m e nt of the an le and the toe s during we ight be aring

Ensure the base of the toe s are supporte d during an m ove m e nt

se a cast shoe if we ight be aring is allowe d

e

n

i

e

6

IN

5

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

6

emovable foot cast using s nthetic, combicast techni ue

IN IC TI N

• • •

ractu re of th e m etatarsals ractu re of tarsals ostoperati e treatm en t after osteosyn th esis of tarsals an d m etatarsals

• Stabilization of h in dfoot m idfoot an d forefoot

IP

NT

elcro strips nonadhe sive hoo elcro strips adhe sive loop 3

igid s nthe tic splint

4

Cut tube bandage s

5

Tube bandage

6

Semirigid casting tape

cm x

cm

cm in dispe nse r box cm

Scissors love s Elastic bandage

P

S NN

1 5 3

owe r e xtremit e movable foot cast using s nthe tic, combicast te chni ue

e

n

i

e

6

P SITI NIN

Place the patie nt supine on a table Place the ne e on a support, and e nsure fre e m ove m e nt of the toe s

SP CI

T IN S T

P IN

IN

• ree m o em en t of th e an kle join t • En su re free m o em en t of th e toes by open in g th e dorsal aspect of th e cast

5 4

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

C

Padding e nsure s the re is e nough space in the foot cast to allow the patie nt to wal without discom fort

Padding holds the toe s apart

old ve or six la e rs of additional padding and appl ove r the e nd of the toe s

Inse rt the padding into a tube bandage to cre ate a roll of padding for the toe s

Ma e a not at one e nd of a se cond tube bandage the not will be place d ove r the rst and se cond toe

Appl the tube bandage to above the an le e nsure the padding re m ains in the de sire d position

Appl additional padding to prote ct the e xte nsor te ndons

Appl te nsion to the not and place it be twe e n the rst and se cond toe

Pre pare the footplate using a la e r rigid splint old the splint to ma e a la e r splint to match the le ngth and width of the foot

an out the splint and trim both e nds

e

n

Appl a small folde d pie ce of padding be twe e n e ach toe

i

e

6

P

Shape the splint li e this

5 5

owe r e xtremit

sing we t glove s m a e s it e asie r to appl the se m irigid casting tape

Appl two la e rs of se m irigid casting tape longitudinall hold in place with circular wraps

Subm e rge the rigid splint in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Appl the footplate splint hold it in place with a la e r of se m irigid casting tape

Appl two adhe sive ve lcro strips with loops to the dorsom e dial side of the cast

Subm e rge an e lastic bandage in wate r using a we t bandage acce le rate s the se tting

Appl the we t bandage using the sam e te chni ue as with the se m irigid casting tape

Mold the arch of the foot using the ball of the thum b do not dorsi e x the toe s

Provide plantar support unde r the toe s and m e tatarsal he ads

If a at sole is ne e de d for the cast, hold a at surface against it

e m ove the we t bandage afte r the cast has se t Ensure the cast has be e n m olde d to the arch of the foot

Trim the cast to allow fre e m ove m e nt of the toe s and an le

e

n

i

e

6

e movable foot cast using s nthe tic, combicast te chni ue

5 6

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Ensure fre e m ove m e nt of the an le oint is possible

e m ove the dorsal distal se ction of the cast to fre e the toe s be gin b ma ing a sm all hole ove r the padding

Inse rt the scissors and split the cast late rall to the base of the fth m e tatarsal

Split the cast down to the base of the rst m e tatarsal and re m ove the padding tube

e aware that during we ight be aring the toe s ne e d m ore space

Ensure the base of the toe s are supporte d during an m ove m e nt

The cast is split from the base of the se cond toe , dire cte d toward the late ral malle olus

The split should be obli ue , and should lie ove r the e xte nsor m uscle s

n

Trim the cast be low the m e dial m alle olus and the late ral m alle olus

e

e m ove the ne e support be fore trim m ing the cast

i

e

6

Klaus Dre sing, os Engele n

e m ove the padding be twe e n the toe s

Mar the splitting line on the dorsal side of the cast

5

owe r e xtremit

e m ove the cast and trim the e dge s

ound off the sharp e dge s and re m ove m m to le ave a gap be twe e n the e dge s

e appl the cast

e

n

i

e

6

e movable foot cast using s nthe tic, combicast te chni ue

Attach two long ve lcro strips with hoo s and wrap the m around the foot unde r te nsion to close the cast

IN

SS SS

NT

re e m ove m e nt of the an le oint is possible

5

Trim the ve lcro strips to the re uire d le ngth with two cuts

The ve lcro strips allow e as re m oval and re application of the cast

The rounde d e dge s of the cast avoid irritation of the inste p The re is e nough space for m ove m e nt of the toe s

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

6

irst toe orthosis using s nthetic, combicast techni ue

IN IC TI N

• •

ractu re of th e rst toe erioperati e protection after h allu x algu s su rgery

• Stabilization of th e rst toe an d rst ray

IP

NT

Se mirigid casting tape igid s nthe tic splint

cm cm x

cm

3 Cut tube bandage s 4 Tube bandage 5 Tube bandage 6

cm in dispe nse r box cm in dispe nse r box

e lcro strip nonadhe sive hoo e lcro strip adhe sive loop Combine d adapte d ve lcro strips adhe sive loop and hoo Scissors love s Elastic bandage

P

S NN

1 5

owe r e xtremit irst toe orthosis using s nthe tic, combicast te chni ue

e

n

i

e

6

P SITI NIN

Place the patie nt supine or se ate d on a table

SP CI

T IN S T

P IN

IN

• irst toe in fu n ction al position • En ou gh in terdigital space to a oid friction an d skin irritation

5

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

C

Appl a sm all tube bandage , with a slit at one e nd, ove r the rst toe

Appl the se m irigid casting tape from late ral, around the fore foot, and the n diagonall to the base of the rst toe

Cut halfwa through the casting tape , from proxim al to distal, for e asie r application be twe e n the rst and se cond toe

Cut again, and wrap once m ore around the rst toe

rap be low the fth toe and across the fore foot, and trim

se two strips of adhe sive ve lcro one with loops and one with hoo s to ope n and close the orthosis

Attach the ve lcro strips half ove rlapping, and trim to the re uire d width

Ensure the ve lcro with loops is be low and the ve lcro with hoo s is above

e m ove the bac ing and attach the adhe sive ve lcro with loops to the se m irigid casting tape

Trim a rigid splint to t the rst toe and the m e dial side of the fore foot

n

Cut an ope ning in the tube bandage for toe s I III and trim the e xce ss

e

Appl a short tube bandage ove r the toe s and part of the foot

i

e

6

P

5

owe r e xtremit irst toe orthosis using s nthe tic, combicast te chni ue

C

e

n

i

e

6

P

5

Subm e rge the rigid splint in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Appl the rigid splint unde r the rst toe and along the m e dial side of the fore foot

Subm e rge the se m irigid casting tape in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Appl the se mirigid casting tape ove r the ve lcro, using the sam e te chni ue as with the rst la e r

Cut halfwa through the casting tape , from proxim al to distal, for e asie r application be twe e n the rst and se cond toe

Subm e rge an e lastic bandage in wate r using a we t bandage acce le rate s the se tting

Attach a sm all strip of adhe sive ve lcro with loops to the m e dial side of the cast ove r the rst toe

Appl the we t bandage ove r the com ple te orthosis

Mold the orthosis to the de sire d position while it se ts

e m ove the we t bandage afte r the orthosis has se t

e fore trim m ing the orthosis to the de sire d shape , it is re m ove d The rst ste p is to ope n the ve lcro

Slide the scissors be ne ath the oute r la e r of the orthosis whe re the ve lcro ove rlaps, and cut through the orthosis

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Close the ve lcro the orthosis m ust be trim m e d to fre e the an le oint and toe s II

The m ate rial be twe e n the rst and se cond toe m ust be re m ove d to avoid friction and s in irritation b the orthosis

Ma e a cut along the inside of the rst toe to allow the orthosis to be ad uste d around the toe

Ope n the orthosis and re m ove it

Trim the orthosis to the de sire d shape , proxim all and distall , to fre e the hindfoot and the toe s II

The se ction ove r the rst toe is also split

Ope n the ve lcro, slide the orthosis ove r the rst toe , and close with the ve lcro

Ensure the orthosis has be e n trim m e d corre ctl and doe s not inte rfe re with fre e m ove m e nt of the toe s

Attach a narrow strip of ve lcro with hoo s to close the orthosis around the rst toe

The ve lcro allows the patie nt to ad ust the orthosis if the re is too m uch pre ssure on the rst toe

n

Slide the scissors be ne ath the tube bandage , and cut through the lowe r la e r of the orthosis

e

Ope n and fold bac the ve lcro the lowe r la e r of the orthosis can be se e n

i

e

6

Klaus Dre sing, os Engele n

5 3

owe r e xtremit irst toe orthosis using s nthe tic, combicast te chni ue

SS SS

NT

re e m ove m e nt of the an le oint and the toe s, e xce pt the rst toe

e

n

i

e

6

IN

5 4

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

TEC NI Spine

ES

Spine

3

Co rs e t u s in g p la s t e r o f Pa ris

5

Co rs e t u s in g s n t e t ic, co m ica s t t e c n i u e

5 3

e m o va le co rs e t u s in g s n t e t ic , co m ica s t t e c n i u e

5

Klaus Dre sing, os Engele n

e

n

i

e

Corset using plaster of Paris

IN IC TI N

•

ractu re of th e low er th oracic spin e • ractu re of th e lu m bar spin e

• Stabilization of th e spin e

IP

NT

Cast padding Plaste r of Paris splint

cm or

3

Plaste r of Paris splint

cm

4

Plaste r of Paris rolls

cm or

5

Cre pe pape r bandage

6

Cut tube bandage or cast shirt

cm cm

Scissors Oscillating saw

P

S NN

1 2 or

5

Spine Corse t using plaster of Paris

P SITI NIN

Ste rn u m

ra vit

e

n

i

e

Pu ic o ne

Stand the patie nt upright be twe e n supports if possible

SP CI

T IN S T

If the patie nt re uire s ane sthe sia, place the patie nt in lordosis using the thre e point principle

P IN

IN

• En su re th e axillary fossa is free • ree m o em en t of th e h ips • Th ree poin t su pport stern u m pu bic bon e lu m bar spin e • Be aw are of th e edges paddin g of th e edges • en tral w in dow to allow n orm al food in take m igh t be n ecessary in slim patien ts

5

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

P

C

Appl a large tube bandage or cast shirt

Appl the padding over the cast shirt, from distal to proximal be aware of bon prominences at the superior anterior iliac spine

Appl a pape r bandage as a barrie r be twe e n the dr padding and the we t POP se the half ove rlapping te chni ue

Subm e rge the roll of POP in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

e inforce the corse t with a ve ntral POP splint, e ithe r in one or two se ctions

Stretch and smooth out the splint, pressing the la ers together, resulting in a compact splint If this procedure is not done, puff pastr plaster will result, causing an unstable splint

Appl the rst POP splint to the front of the corse t

Appl we t rolls of POP ove r the POP splint, using the half ove rlapping te chni ue

Appl a long POP splint to the bac of the corse t

Appl a se cond POP splint to the front of the corse t and trim the e xce ss

e

a lf o ve rla p p in g

e

n

i

se the half ove rlapping te chni ue

Appl the roll of POP using the half ove rlapping te chni ue

5

Spine

Appl anothe r la e r of POP to cove r the splints, using the half ove rlapping te chni ue

Sm ooth out the corse t

Mold the corse t to the iliac cre sts

Mold the corset while it is setting, to provide support for the sternum and the lumbar spine

Tap on the corse t to che c it has se t and m ar the e dge s of the cast for trim ming

Ensure the axillae are fre e to provide unhinde re d m ove m e nt of the shoulde rs

Mar the pubic bone and the iliac cre sts the m ust be fre e of m ate rial

Mar the com ple te splitting line on the corse t

The saw blade oscillate s and doe s not rotate , so the re is no dire ct harm to the s in

e m ove the e xce ss mate rial with the oscillating saw or a plaste r nife

e

n

i

e

Corse t using plaster of Paris

5

The nal shape of the corse t afte r trim ming

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

old bac the cast shirt ove r the corse t and pre ss onto the we t POP

Appl we t rolls of POP to give a sm ooth nish to the e dge s of the corse t

Sm ooth out the POP to give an e ve n nish

e pe at the proce dure at the distal borde r of the corse t

n

Appl we t rolls of POP to the e dge s of the trim m e d corse t

e

e m ove the e xce ss cast shirt le ave e nough to fold ove r the corse t

i

e

Klaus Dre sing, os Engele n

Appl we t rolls of POP to give a sm ooth nish to the e dge s of the corse t

5

Spine Corse t using plaster of Paris

SS SS

NT

The e dge s of the corse t are sm ooth

The axillae are com ple te l fre e

re e m ove m e nt of the shoulde rs, hips and lowe r bod is possible

e

n

i

e

P IN C

ip e xion of at le ast is possible to allow com fortable sitting

The re are two or thre e nge r s bre adth be twe e n the distal borde r of the corse t and the se ating are a

Ste rn u m

u m a r sp in e

Pu ic o n e

The corse t supports the ste rnum , lum bar spine , and pubic bone the thre e point principle

C

S T

Mar the splitting line

5

Split the corse t with the oscillating saw

Cut through the padding and the cast shirt with scissors, and re m ove the corse t

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

Corset using s nthetic, combicast techni ue

IN IC TI N

•

ractu re of th e low er th oracic spin e • ractu re of th e lu m bar spin e

• Stabilization of th e spin e

IP

NT

Adhe sive foam padding igid s nthe tic splint cm x cm

cm or

3

Cut tube bandage or cast shirt

4

Semirigid casting tape

5

Scissors

6

love s

cm or

cm

Elastic bandage

P

S NN

1 2 or

5 3

Spine Corse t using s nthe tic, com bicast te chni ue

P SITI NIN

Ste rn u m

ra vit

e

n

i

e

Pu ic o ne

Stand the patie nt upright be twe e n supports if possible

SP CI

T IN S T

If the patie nt re uire s ane sthe sia, place the patie nt in lordosis using the thre e point principle

P IN

IN

• En su re th e axillary fossa is free • ree m o em en t of th e h ips • Th ree poin t su pport stern u m pu bic bon e lu m bar spin e • Be aw are of th e edges paddin g of th e edges • en tral w in dow to allow n orm al food in take m igh t be n ecessary in slim patien ts

5 4

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

C

e

P

i

Subm e rge the se m irigid casting tape in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

n

Appl adhe sive foam padding to prote ct the iliac cre sts and the ste rnum

e

Appl a large tube bandage or cast shirt

a lf ove rla p p in g

Appl the se m irigid casting tape start b cove ring the foam padding ove r the iliac cre sts

Continue the application, using the half ove rlapping te chni ue

Exte nd the se m irigid casting tape to cove r the foam padding prote cting the ste rnum

Subm e rge the rigid splint in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Appl the rst rigid splint ante riorl , and hold it in place with anothe r la e r of se m irigid casting tape

Appl a se cond rigid splint at the le ve l of the iliac cre st, and hold it in place with se m irigid casting tape

Trim the rigid splint e nsure that it doe s not com ple te l e ncircle the bod

Trim the rst rigid splint to the de sire d le ngth

Subm e rge an e lastic bandage in wate r using a we t bandage acce le rate s the se tting

5 5

Spine Corse t using s nthe tic, com bicast te chni ue

Ste rn u m

u m a r sp in e

Appl the we t e lastic bandage ove r the se m irigid casting tape

e

n

i

e

Pu ic on e

Ensure the re is support of the ste rnum , lum bar spine , and pubic bone to cre ate the re uire d lordosis

Mar the e dge s of the corse t for trim m ing

Cut the cast shirt fre e and fold it bac ove r the corse t

5 6

e m ove the we t bandage afte r the corse t has se t

Ensure the axillae and the hips are fre e of m ate rial

Trim the corse t along the mar e d line s with the scissors

Ensure the re is e nough space around the axillae to allow fre e m ove m e nt of the shoulde rs

Appl anothe r la e r of we t se m irigid casting tape to hold the e dge s of the cast shirt in place

Appl a we t e lastic bandage to acce le rate the nal se tting

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

e

Klaus Dre sing, os Engele n

n

i

e m ove the we t bandage afte r the corse t has se t

e

e pe at the proce dure at the distal borde r of the corse t

IN

SS SS

NT

The axillae are com ple te l fre e

re e m ove m e nt of the shoulde rs, hips and lowe r bod is possible

ip e xion of at le ast com fortable sitting

is possible to allow

Ste rn u m

u m a r sp in e Pu ic on e

The re are two or thre e nge r s bre adth be twe e n the distal borde r of the corse t and the se ating are a

The corse t supports the ste rnum , lum bar spine , and pubic bone the thre e point principle

5

Spine

e

n

i

e

Corse t using s nthe tic, com bicast te chni ue

5

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

3

emovable corset using s nthetic, combicast techni ue

IN IC TI N

•

ractu re of th e low er th oracic spin e • ractu re of th e lu m bar spin e

• Stabilization of th e spin e

IP

NT

Adhe sive foam padding igid s nthe tic splint cm x cm

cm or

3

Cut tube bandage or cast shirt

4

Semirigid casting tape

5

Scissors

6

cm or

cm

elcro straps or rive t straps love s Elastic bandage

P

S NN

1 2 or

5

Spine

3

e movable corse t using s nthe tic, combicast te chni ue

P SITI NIN

Ste rn u m

ra vit

e

n

i

e

Pu ic o ne

Stand the patie nt upright be twe e n supports if possible

SP CI

T IN S T

If the patie nt re uire s ane sthe sia, place the patie nt in lordosis using the thre e point principle

P IN

IN

• En su re th e axillary fossa is free • ree m o em en t of th e h ips • Th ree poin t su pport stern u m pu bic bon e lu m bar spin e • Be aw are of th e edges paddin g of th e edges • en tral w in dow to allow n orm al food in take m igh t be n ecessary in slim patien ts • Th e caregi er sh ou ld explain h ow best to rem o e an d reapply th e corset

6

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

C

e

P

3

Klaus Dre sing, os Engele n

i

Subm e rge the se m irigid casting tape in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

n

Appl adhe sive foam padding to prote ct the iliac cre sts and the ste rnum

e

Appl a large tube bandage or cast shirt

a lf ove rla p p in g

Appl the se m irigid casting tape start b cove ring the foam padding ove r the iliac cre sts

Continue the application, using the half ove rlapping te chni ue

Exte nd the se m irigid casting tape to cove r the foam padding prote cting the ste rnum

Subm e rge the rigid splint in wate r for a fe w se conds, re m ove , and s ue e e out e xce ss wate r

Appl the rst rigid splint ante riorl , and hold it in place with anothe r la e r of se m irigid casting tape

Appl a se cond rigid splint at the le ve l of the iliac cre st, and hold it in place with se m irigid casting tape

Trim the rigid splint e nsure that it doe s not com ple te l e ncircle the bod

Trim the rst rigid splint to the de sire d le ngth

Subm e rge an e lastic bandage in wate r using a we t bandage acce le rate s the se tting

6

Spine

3

e movable corse t using s nthe tic, combicast te chni ue

Ste rn u m

u m a r sp in e

Appl the we t e lastic bandage ove r the se m irigid casting tape

e

n

i

e

Pu ic on e

Ensure the re is support of the ste rnum , lum bar spine , and pubic bone to cre ate the re uire d lordosis

Mar the e dge s of the corse t for trim m ing

Cut the cast shirt fre e and fold it bac ove r the corse t

6

e m ove the we t bandage afte r the corse t has se t

Ensure the axillae and the hips are fre e of m ate rial

Trim the corse t along the mar e d line s with the scissors

Ensure the re is e nough space around the axillae to allow fre e m ove m e nt of the shoulde rs

Appl anothe r la e r of we t se m irigid casting tape to hold the e dge s of the cast shirt in place

Appl a we t e lastic bandage to acce le rate the nal se tting

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

C

e

P

3

Klaus Dre sing, os Engele n

n

i

e m ove the we t bandage afte r the corse t has se t

e

e pe at the proce dure at the distal borde r of the corse t

IN

SS SS

NT

The axillae are com ple te l fre e

re e m ove m e nt of the shoulde rs, hips and lowe r bod is possible

ip e xion of at le ast com fortable sitting

is possible to allow

Ste rn u m

u m a r sp in e Pu ic on e

The re are two or thre e nge r s bre adth be twe e n the distal borde r of the corse t and the se ating are a

The corse t supports the ste rnum , lum bar spine , and pubic bone the thre e point principle

6 3

Spine

SP ITTIN

N

PP

IN

Mar the splitting line on the late ral side of the corse t

Split the corse t using the cast scissors

e lcro straps or rive t straps are applie d to m a e ope ning and closing e asie r

The patie nt can put on, or ta e off, the corse t without an he lp

Ad ustm e nts can be made with the straps The straps should be full tighte ne d to e e p the corse t in the corre ct position

The alte rnate dire ction of the straps avoids an rotation of the corse t

e

n

i

e

3

e movable corse t using s nthe tic, combicast te chni ue

6 4

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

TEC NI Support bandages

ES

Support bandages

Co lla r a n d cu ff Cla vicle

a n d a ge

a n d a ge

3

ilc ris t

4

ris t

6

a n d a ge

a n d a ge

5

l o

6

n le a n d fo o t

6

6 5 6

a n d a ge

6 3 a n d a ge

6

Klaus Dre sing, os Engele n

e

n

i

e

Collar and cuff bandage

IN IC TI N

•

ractu re of th e su pracon dylar h u m eru s in ch ildren • Tem porary im m obilization in proxim al diaph yseal h u m eral fractu res an d sh ou lder in ju ries in adu lts

• Elbow in exion to m ain tain position depen din g on th e exten t of sw ellin g

IP

NT

Cast padding Cut tube bandage 3

Tube bandage

4

Scissors

P

S NN

cm in dispe nse r box

1 6

Support bandage s Collar and cuff bandage

e

n

i

e

P SITI NIN

Se at the patie nt com fortabl on a stool In childre n e lbow in gre ate r than

e xion

In adults e lbow in functional position

e xion

SP CI

T IN S T

P IN

IN

• Sw ellin g • ircu lation • Skin irritation u n der th e axilla • In adu lts tem porary im m obilization on ly

6

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

C

e

P

old the padding in half le ngthwa s

Inse rt the folde d padding into the tube bandage

oll out the tube bandage ove r the padding to m a e a padde d roll

Place the padde d roll around the ne c of the patie nt

Ma e a not in the padde d roll to x the sling

e nd the e lbow and pass the padde d roll around the wrist Ma e a not to x the wrist in place

Trim the e xce ss tube bandage with the scissors

i

Eight la e rs of padding are laid out

e

n

To m a e the collar and cuff, a tube bandage is rolle d inside out

6

Support bandage s Collar and cuff bandage

SS SS

NT

Che c that the bandage is not too tight b ta ing the pulse

Che c the re is suf cie nt padding around the ne c

Adapt the e xion of the e lbow to the am ount of swe lling oose n the not and slide it up the padde d roll

e tighte n the not at the de sire d position

e

n

i

e

IN

Im portant As the mate rial lose s te nsion, it is ne ce ssar to ad ust the collar and cuff afte r a fe w da s

oll bac the tube bandage and trim the e xce ss padding

e tie the not to hold the wrist at the de sire d position

6

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

Clavicle bandage

IN IC TI N

•

•

ractu re of th e cla icle

etraction of both sh ou lders to pre en t o erlappin g of th e en ds of th e cla icu lar fractu re

IP

NT

Cast padding Cut tube bandage 3

Tube bandage

4

Scissors

P

S NN

cm in dispe nse r box

1 6

Support bandage s Clavicle bandage

e

n

i

e

P SITI NIN

Se at the patie nt com fortabl on a stool Place the affe cte d lim b hanging in the functional position

SP CI

T IN S T

P IN

IN

• ircu lation • Irritation of th e brach ial plexu s • Skin irritation u n der th e axillae • Bew are of arm sw ellin g du e to redu ced en ou s drain age

6

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

C

e

P

old the padding in half le ngthwa s

Inse rt the folde d padding into the tube bandage

oll out the tube bandage ove r the padding to m a e a padde d roll

Place the padde d roll around the bac of the patie nt s ne c and unde r both axillae Exte nd the shoulde rs unde r slight te nsion

Tie the e nds of the bandage toge the r

Pull toge the r the se ctions be hind the ne c and the bac to cre ate m ore te nsion

Tie toge the r both se ctions be twe e n the shoulde r blade s

i

Eight la e rs of padding are laid out

e

n

To m a e a clavicle bandage , a tube bandage is rolle d inside out

6 3

Support bandage s Clavicle bandage

SS SS

NT

Che c that the bandage is not too tight b ta ing the pulse

Che c se nsation in the uppe r e xtre m itie s and s in irritation unde r the bandage

e

n

i

e

IN

6 4

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

3

ilchrist bandage

IN IC TI N

• ractu re of th e proxim al h u m eru s • Sh ou lder in ju ries

• Stabilization of th e proxim al h u m eru s an d th e sh ou lder

IP

NT

Cast padding Cut tube bandage 3

Tube bandage

4

Safe t pins

P

S NN

cm in dispe nse r box

1 6 5

Support bandage s

P SITI NIN

e

n

i

e

3

ilchrist bandage

Se at the patie nt com fortabl on a stool Place the affe cte d lim b hanging with

e xion in the e lbow

SP CI

T IN S T

P IN

IN

• Skin irritation u n der th e axilla • ircu lation

6 6

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Slide the tube bandage ove r the affe cte d arm and around the ne c

i

Ma e an ope ning in the m iddle of the tube bandage for the affe cte d arm

e

Se le ct a tube bandage to tim e s the le ngth of the patie nt s arm The le ngth of the tube bandage ma var de pe nding on the si e of the patie nt s waist

e

C

n

P

3

Klaus Dre sing, os Engele n

old the padding le ngthwa s and inse rt into the tube bandage to pre ve nt e xce ssive pre ssure on the ne c

Ma e an ope ning in the tube bandage distall , to fre e the hand and allow m ove m e nt of the nge rs

The distal se ction of the tube bandage will be passe d around the patie nt s bac

The proximal se ction of the tube bandage is m ade into a sling to support the fore arm , and xe d with safe t pins or clips

rap the distal se ction of the tube bandage around the bod it should pass be twe e n the bod and the affe cte d arm

rap the tube bandage around the uppe r arm and x in place dorsall with safe t pins or clips

Trim the e xce ss tube bandage with scissors

6

Support bandage s

IN

SS SS

NT

e

n

i

e

3

ilchrist bandage

6

Ensure the fore arm is supporte d Ensure the re is fre e m ove m e nt of the wrist

Che c that the bandage is not too tight b ta ing the pulse Che c sensation in the upper e xtre mitie s and s in irritation unde r the bandage

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

4

rist bandage

IN IC TI N

• Strain • Sprain

• Stabilization an d pain relief

IP

NT

Elastic bandage andage clips 3

Surgical tape

4

Scissors

P

S NN

1 6

Support bandage s

P SITI NIN

e

n

i

e

4

rist bandage

Se at the patie nt com fortabl on a stool Place the affe cte d lim b on the table in a functional position

SP CI

T IN S T

P IN

IN

• A ban dage of appropriate size is applied w ith th e ban dage roll alw ays facin g ou tw ard • Ban dages are n orm ally applied in a pron ated direction from distal to proxim al • Th e extrem ity sh ou ld n ot be pu lled in an extrem e pron ate or su pin ate position by th e ban dage • Each diagon al tu rn n eeds to be xed w ith a straigh t circu lar tu rn • Be aw are of an u n diagn osed scaph oid fractu re

6

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

C

e

P

4

Klaus Dre sing, os Engele n

The ne xt wrap follows the m e tacarpal he ads, the n afte r anothe r cut, passe s be twe e n the thum b and inde x nge r

i

Cut halfwa through the bandage , from proxim al to distal, to avoid e xce ssive folds be twe e n the thum b and inde x nge r

rap from the ulnar st loid proce ss, ove r the hand and be twe e n the thum b and inde x nge r

n

e gin late rall the rst wrap is diagonal towards the base of the thum b

e

Ensure the bandage roll alwa s face s outward

rap from late ral to the base of the thum b

a lf ove rla p p in g

If the fore arm is of uniform width, wrap from distal to proxim al, using the half ove rlapping te chni ue

If the fore arm is tape re d, use the criss cross te chni ue up to the e lbow

Criss cro ss

Ke e p the bandage close to the arm at all tim e s

Se cure the bandage with surgical tape or bandage clips at a place that doe s not irritate the patie nt

6

Support bandage s

IN

SS SS

NT

Circulation is not re stricte d

e

n

i

e

4

rist bandage

6

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

5

Elbow bandage

IN IC TI N

• Strain • Sprain

• Stabilization an d pain relief

IP

NT

Elastic bandage andage clips 3

Surgical tape

4

Scissors

P

S NN

1 6 3

Support bandage s

P SITI NIN

e

n

i

e

5

Elbow bandage

Se at the patie nt com fortabl on a stool Place the e lbow in

e xion

SP CI

T IN S T

P IN

IN

• A ban dage of appropriate size is applied w ith th e ban dage roll alw ays facin g ou tw ard • Ban dages are n orm ally applied in a pron ated direction from distal to proxim al • Th e extrem ity sh ou ld n ot be pu lled in an extrem e pron ate or su pin ate position by th e ban dage • Each diagon al tu rn n eeds to be xed w ith a straigh t circu lar tu rn

6 4

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

C

e

P

5

Klaus Dre sing, os Engele n

The ne xt wrap follows the m e tacarpal he ads, the n afte r anothe r cut, passe s be twe e n the thum b and inde x nge r

i

Cut halfwa through the bandage , from proxim al to distal, to avoid e xce ssive folds be twe e n the thum b and inde x nge r

rap from the ulnar st loid proce ss, ove r the hand and be twe e n the thum b and inde x nge r

n

e gin late rall the rst wrap is diagonal towards the base of the thum b

e

Ensure the bandage roll alwa s face s outward

rap from late ral to the base of the thum b

a lf ove rla p p in g

If the fore arm is of uniform width, wrap from distal to proxim al, using the half ove rlapping te chni ue

If the fore arm is tape re d, use the criss cross te chni ue

Criss cro ss

se the gure of e ight te chni ue at the e lbow to avoid an e xce ssive am ount of la e rs

ix the gure of e ight in place with circular wraps

6 5

Support bandage s

Se cure the bandage with surgical tape or bandage clips at the uppe r arm

e

n

i

e

5

Elbow bandage

IN

SS SS

The e lbow is in not re stricte d

6 6

NT

e xion and circulation is

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

Klaus Dre sing, os Engele n

e

n

i

e

6

An le and foot bandage

IN IC TI N

• An kle sprain • In stability of th e an kle join t

• Stabilization of th e an kle join t

IP

NT

Elastic bandage andage clips 3

Surgical tape

4

Scissors

P

S NN

1 6

Support bandage s

P SITI NIN

e

n

i

e

6

An le and foot bandage

Place the patie nt supine or se ate d with the ne e on a support Place the an le in

e xion

SP CI

T IN S T

P IN

IN

• A ban dage of appropriate size is applied w ith th e ban dage roll alw ays facin g ou tw ard • Ban dages are n orm ally applied in a pron ated direction from distal to proxim al • Th e extrem ity sh ou ld n ot be pu lled in an extrem e pron ate or su pin ate position by th e ban dage • Each diagon al tu rn n eeds to be xed w ith a straigh t circu lar tu rn

6

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

C

Start late rall and wrap once around the fore foot

Pass the bandage diagonall ove r the he e l and across the subtalar oint

Pass the bandage ove r the m e dial m alle olus

Pass the bandage ove r the Achille s te ndon and diagonall be ne ath the foot

Se cure the bandage on the late ral side with a nge r and pass the bandage ove r the m e dial arch

Pass the bandage across the late ral m alle olus and the Achille s te ndon

Pass the bandage be ne ath the foot to the late ral side pull the late ral side of the foot up slightl

n

Ensure that the roll of bandage face s outward not inward

e

Avoid supination b wrapping the foot in pronation

i

e

P

6

Klaus Dre sing, os Engele n

a lf ove rla p p in g

rap the lowe r le g, from distal to proxim al, using the half ove rlapping te chni ue

Now wrap the bandage from proximal to distal wrap from late ral to m e dial across the m e dial malle olus

6

Support bandage s

Pass the bandage ove r the Achille s te ndon and diagonall be ne ath the foot

Pass the bandage across the foot and ove r the late ral m alle olus and the Achille s te ndon

Pass the bandage be ne ath the foot and appl a circular wrap around the foot

e

n

i

e

6

An le and foot bandage

rap the re m aining bandage ove r the Achille s te ndon and se cure with surgical tape or bandage clips

IN

SS SS

NT

The circulation m ust not be re stricte d The an le oint is in e xion

63

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

APPENDIX

Appendix

Ca s t s a n d Sp lin t s —In s t ru ct io n s fo r Pa t ie n t s This docum e nt is available from AOTraum a and the Thie m e Me dia Ce nte r we bsite

6 33

Casts and Splints—Instructions for Patients

x i d n e

Casts an d splin ts u su ally in clu de paddin g or cu sh ion in g to protect th e skin , th e bon es, an d an y n erves th at are close to th e su r ace. You m u st leave th is paddin g w h ere it is so th e cast con tin u es to protect you . Casts an d splin ts sh ou ld on ly ever be taken o or ch an ged w h en advised by you r doctor. You r doctor h as recom m en ded a cast or splin t as part o you r treatm en t. Bu t sin ce each person an d th eir m edical problem s are u n iqu e, th e o llow in g in orm ation provides gen eral in stru ction s on ly on h ow best to look a ter you r in ju ry an d you r cast. How ever, i at an y tim e you develop an y o th e w arn in g sign s described, or h ave an y qu estion s or w orries, con tact you r doctor im m ediately.

p

p

A cast is a h ard ban dage w rapped arou n d you r arm or leg to su pport an d protect an in ju ry su ch as a broken bon e, a sprain , or th e site o an operation . Th e cast h olds th e in ju red area still an d straigh t, protectin g it du rin g h ealin g, an d h elps to relieve pain . A splin t is a rm su pport, like a cast, bu t th e h ard part does n ot w rap all th e w ay arou n d you r in ju red lim b, allow in g som e room or sw ellin g.

a

arning signs

a

hat is a cast

p

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i

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Casts and Splints— Instructions for Patients

You sh ou ld con tact you r doctor im m ediately i you develop an y o th e ollow in g w arn in g sign s: • Cast/ splin t is too tigh t • Fin gers or toes are sw ollen (a little is n orm al; a lot is bad) • Nu m bn ess (loss o eelin g) in n gers or toes • Can ’t m ove n gers or toes • Pain keeps gettin g w orse • “Hot spot” (bu rn in g an d/ or ru bbin g) u n der th e cast.

itte n r w t u o h t e wi v a e l t n Do ro m f s n o i t c s tru n i p u ne w o o h p fo ll e l e t in g d u l c n i , r o o u r d o ct n e xt d n a , s s d d re a , r e b m nu d a te t n e m t n appoi

633

Appe ndix Instructions for Patients

You r lim bs u su ally sw ell ollow in g a seriou s in ju ry. To redu ce th e sw ellin g, rest an d elevate th e in ju red area above th e level o you r h eart. An in ju red oot or an kle sh ou ld be u p on pillow s w h ile you are lyin g or sittin g partially u prigh t. On ce elevated, gen tle n ger or toe m otion is alrigh t, bu t vigorou s u se m ay irritate th e in ju red area, in creasin g sw ellin g an d pain .

a

p

p

e

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d

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x

ow to prevent swelling

Apply ice to th e in ju red area u sin g a w aterproo bag. Th is h elps relieve pain an d sw ellin g, even th rou gh th e cast or ban dage.

ow to prevent stiffne ss As soon as you can , com pletely ben d an d straigh ten th e n gers/ toes o you r in ju red lim b or a ew secon ds every h ou r w h ile you are aw ake. Gen tle stretch in g o th e join ts above th e cast (elbow , sh ou lder, kn ee, h ip) is also a good idea in m ost cases. Even i n ot in ju red, you r sh ou lder especially can becom e sti an d u n com ortable i n ot u sed n orm ally or lon g periods o tim e. I n eeded, u se you r oth er h an d to h elp m ove lim bs an d join ts th rou gh a u ll ran ge o m otion .

Ca s t s a n d Sp lin t s —In s t ru ct io n s fo r Pa t ie n t s

634

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton

al ing on our cast

p

e

n

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i

x

o to r m a e v i r e to d f a s t o n It is , with e l c c i b rid e a r o , e l c i ve h r le g o m r a r ou n o t s a c a

a

p

Som e leg casts allow th e patien t to pu t w eigh t on th eir leg or even to w alk w h ile w earin g th e cast (on ce it h as com pletely dried). Walkin g casts m ay h ave an attach ed h eel or th is pu rpose, or be provided w ith a rem ovable cast sh oe. I you r cast is n ot in ten ded or w alkin g you m u st obtain cru tch es or a w alkin g ram e, an d learn h ow to u se th ese sa ely. Ch eck w ith you r doctor or speci c in stru ction s.

Ta ing care of our cast Wh ile casts are m ade o stron g m aterial th ey can still be easily dam aged, redu cin g th eir e ectiven ess. Follow th ese sim ple gu idelin es to keep you r cast w orkin g properly. • Keep you r cast dry: Plaster casts “m elt” i th ey get w et, an d you r skin can be h arm ed rom w et paddin g. Alw ays u se a w aterproo cover or h eavy plastic bag w h en sh ow erin g (n o sw im m in g or bath s), an d u se a h air dryer set to a low tem peratu re i it becom es dam p. Con tact you r doctor i th e cast becom es sign i can tly w et.

• Keep you r cast clean : Avoid dirty or du sty places, beach es, elds, etc, an d avoid activities th at m igh t soil you r cast. • Don ’t overh eat you r cast: I you r cast is n ear a h eater or replace it can becom e overh eated an d bu rn you . • Don ’t pu t an yth in g in side you r cast: Som etim es you r skin itch es in side th e cast. Th is can be relieved by applyin g an ice pack, or placin g a h air dryer or vacu u m clean er again st on e o th e en ds o th e cast to draw air th rou gh it an d across you r skin .

• Is m y cast too tigh t? Casts sh ou ld eel sn u g, bu t n ot too tigh t. Tigh tn ess develops rom sw ellin g in side th e cast. Elevate an d rest th e lim b. Even tu ally, th e sw ellin g decreases. I tigh tn ess does n ot im prove, call you r doctor prom ptly. • Is m y cast too loose? Som etim es, as h ealin g progresses, th e cast begin s to eel loose. Th is can u su ally be ch ecked by you r doctor du rin g a rou tin e ollow -u p, bu t i th e cast slides sign i can tly u p or dow n you r lim b it sh ou ld be ch ecked prom ptly. • Wh at i m y cast gets so t or breaks? Th is can h appen w ith an y type o cast resu ltin g in a cast th at does n ot protect you r in ju ry w ell, or th at irritates you r skin , perh aps cau sin g blisters or sores. Visit you r doctor to get th e cast repaired or replaced. I it’s on you r leg, stop w alkin g on th e cast an d u se cru tch es. • How abou t jew elry an d n ail polish ? Im m ediately a ter an in ju ry, rem ove an y rin gs, bracelets, an d body piercin gs. Becau se o sw ellin g, th ey can becom e too tigh t. You r doctor m ay ask you to rem ove n ail polish or arti cial n ails.

3

635

Appe ndix Instructions for Patients

Cast removal and re cover

a

p

p

e

n

d

i

x

You r cast w ill be rem oved w ith eith er scissors or a special cast saw th at vibrates its w ay th rou gh th e cast. Even th ou gh you r in ju ry h as started to h eal, th e join ts in side w ill becom e sti , an d m u scles h ave becom e w eaker. Skin an d h air grow th m ay ch an ge u n der th e cast, bu t th ese u su ally resolve a ter cast rem oval. How ever, m u scles an d join ts requ ire several m on th s o exercise an d u se be ore th ey h ave u lly recovered.

Never rem ove you r cast by you rsel . You m ay in ju re you rsel or distu rb th e h ealin g process. Th ese in stru ction s h ave been provided by orth opedic specialists w ith m an y years’ experien ce treatin g patien ts w ith casts an d splin ts. Follow in g th ese sim ple in stru ction s w ill h elp you to ach ieve th e best possible resu lt or you r in ju ry, an d w ill h elp you get back to w ork an d play as qu ickly an d as sa ely as possible.

Since eve r patient and eve r in ur is uni ue, ou mu st obtain and follo w our own doctor s advice

The AO oundation is a m e dicall guide d nonpro t organi ation le d b an inte rnational group of surge ons spe ciali e d in the tre atm e nt of traum a and disorde rs of the m usculos e le tal s ste m

4

636

Ha z a rd s

Le g a l re s t ric t io n s

re at care has be e n ta e n to m aintain the accurac of the inform ation con taine d in this publication owe ve r, the publishe r, and or the distributor, and or the e ditors, and or the authors cannot be he ld re sponsible for e rrors or an conse ue nce s arising from the use of the inform ation containe d in this publication Contributions publishe d unde r the nam e of individual authors are state m e nts and opinions sole l of said authors and not of the publishe r, and or the distributor, and or the AO roup The products, proce dure s, and the rapie s de scribe d in this wor are ha ardous and are the re fore onl to be applie d b ce rti e d and traine d m e dical profe ssionals in e nvironm e nts spe ciall de signe d for such proce dure s No sugge ste d te st or proce dure should be carrie d out unle ss, in the use r s profe ssional udgm e nt, its ris is usti e d hoe ve r applie s products, proce dure s, and the rapie s shown or de scribe d in this wor will do this at the ir own ris e cause of rapid advance s in the m e dical scie nce s, AO re com m e nds that inde pe nde nt ve ri cation of diagnosis, the rapie s, drugs, dosage s, and ope ration m e thods should be m ade be fore an action is ta e n Although all adve rtising m ate rial which m a be inse rte d into the wor is e xpe cte d to conform to e thical m e dical standards, inclusion in this publication doe s not constitute a guarante e or e ndorse m e nt b the publishe r re garding ualit or value of such product or of the claim s m ade of it b its m anufacture r

This wor was produce d b AO oundation, Swit e rland All rights re se rve d This publication, including all parts the re of, is le gall prote cte d b cop right An use , e xploitation or com m e rciali ation outside the narrow lim its se t forth b cop right le gislation and the re strictions on use laid out be low, without the publishe r s conse nt, is ille gal and liable to prose cution This applie s in particu lar to photostat re production, cop ing, scanning or duplication of an ind, translation, pre paration of m icro lm s, e le ctronic data proce ssing, and storage such as m a ing this publication available on Intrane t or Inte rne t Som e of the products, nam e s, instrum e nts, tre atm e nts, logos, de signs, e tc re fe rre d to in this publication are also prote cte d b pate nts and trade m ar s or b othe r inte lle ctual prope rt prote ction laws e g, AO , ASI , AO ASI , T IAN E O E ogo are re giste re d trade m ar s e ve n though spe ci c re fe re nce to this fact is not alwa s m ade in the te xt The re fore , the appe arance of a nam e , instrum e nt, e tc without de signation as proprie tar is not to be construe d as a re pre se ntation b the publishe r that it is in the public dom ain e strictions on use The rightful owne r of an authori e d cop of this wor m a use it for e ducational and re se arch purpose s onl Single im age s or illustrations m a be copie d for re se arch or e ducational purpose s onl The im age s or illustrations m a not be alte re d in an wa and ne e d to carr the following state m e nt of origin Cop right b AO oundation, Swit e rland

Cop right

Davos Plat

b AO oundation, Swit e rland, Clavade le rstrasse

,C

Ca s t s a n d Sp lin t s —In s t ru ct io n s fo r Pa t ie n t s

Ca s t s , Sp lin t s , a n d Su p p o r t Ba n d a ge s —No n o p e ra t ive Tre a t m e n t a n d Pe rio p e ra t ive Pro t e ct io n

Klaus Dre sing, Pe te r Trafton