Post on 04-Jan-2017
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Plaster and Orthopaedic Appliance
Dr TSE Lung Fung
Dept. of O&T, Prince of Wales Hospital
Casting Material
&
Clinical Applications
Functions
• To maintain support
• To protect realigned bone
• To promote healing & early weight bearing
• To prevent / correct deformity
Types of Cast
1. P.O.P.: CaSO4.2H2O
e.g. Gypsona
2. Synthetic Resin : C6H5.NCO
e.g. Scotchcast, Dynacast
Paster of Paris (POP)
Advantages
• good molding capacity
• easy to handle
• inexpensive
Disadvantages
• weaker than synthetic material
• non-water resistant
• radiolucency fair
Synthetic Material
Advantages
• light
• short setting time
• more radiolucent
• water resistant
• better ventilation
• different colours available
Synthetic Material
Disadvantages
• expensive
• less molding capability
• sticky when applying
Assessment
• History taking • allergic
• mechanism of injury
• medical history
• social background
• Physical assessment • vascular status
• neurological status
• skin integrity
• alignment and position
• Explain the purpose of immobilization and
area involved
• Describe sensation patient may experience
when applying the cast
Psychological consideration
Application of cast
• Padding
• Activation of cast materials
– Immerse in luke warm water at a 30o angle to the vertical
– Gentle squeeze until no more bubbles appear
– Remove from the water and squeeze out excessive water
• Applications
– Circular
– Slab
– Pattern
Technique for applying a cast
• a stockinette - extending to the joint above and longer than the limb (fold back at the end to make a smooth edge)
• take up the slack of every layer to be covered by the coming fold
• smooth out every layer to remove air
• apply with continuous folds to cover at least half of the previous fold
• use the thenar areas of the hands for molding
• the cast must be fit the external anatomy of the limb, mold to create a three-point fixation
Complication
• Circulatory disturbance
• Compression of peripheral nerves
• Edema
• Pressure sore
• Joint stiffness and muscle atrophy
• Allergy
• Infection
Circulatory & Nerve Impairment
Causes
• Unexpected excessive swelling
• Insufficient padding to allow for expected
swelling
• Cast being too tightly
• Local pressure on areas where the blood
vessels or nerves are close to the skin
Circulatory & Nerve Impairment
• Arterial compression
– check toe or finger nails for signs of ischaemia
• Venous compression
– Increase in swelling
• Nerve compression
– Numbness, loss of motion, pain
Radial nerve palsy-cast impingement
Circulatory & Nerve Impairment
Treatment
• Elevation
• Encourage movement of the extremities
• Bivalve the cast
Risk of Disuse Syndrome
• Exercise joints above and below the
affected limb
• Strengthening exercises
Impaired Skin Integrity
– Dress wound properly
– Ensure the edges of the cast are well padded
– Handle the cast with the palms of the hands instead of the fingers to prevent indentations in the soft plaster
– Assist in reposition of patient
– Aware of plaster sore
Plaster Sore
• Causes
– uneven bandaging
– too tight
– foreign body
Plaster Sore
• S/S
– itching
– burning sensation
– fever
– sleep disturbance
– foul smell
– discharge
Risk of Loss of Alignment
• Maintain the reduction and keep the affected part in a
desired position during cast application
• Promote drying of the unconsolidated cast
• Use pillow to support the cast
• Support the cast with palms
• Window piece should put back after inspection
Check for cracks/ softening/ loosening
Weight bearing is not allowed until cast is dry
Body Image Disturbance
• Allow to choose the preferable colour
• Discuss expectation of activity and
appearance of cast
Knowledge Deficit
• Assess concern and knowledge of cast care
• Provide pamphlet in Care of Cast and
discuss in adaptation of daily activities
Demonstration
and
Hands-on Practice
Traction
Traction
Aims
• to reduce and stabilize a fracture or dislocation
• to relieve pain and reduce muscle spasm
• to immobilize a joint or part of the body
• to treat joint pathology
Skin Traction
• Traction via the friction created between skin and the applied taping
• Complication
– Allergic reactions to the adhesive
– Excoriation of the skin
– Malleolar/ heel sores
– Common peroneal nerve compression at the fibular neck
Skeletal Traction
• Traction through skeleton via transosseous pin
• Effective and efficient
• Traction pins
– Steinmann pin
– Kirschner wire
Skeletal Traction
Complications
• Neurovascular injury during pin insertion
• Pin tract infection
• Muscle atrophy and joint contractures
• Deep vein thrombosis of lower limbs
• Compartment syndrome
• Pressure sores
• Cardiopulmonary decompensaton
Buck’s Unilateral Leg Traction
• Temporally stabilization of hip fracture to
relieve pain and muscle spasm
Buck’s Unilateral Leg Traction
– Ensure skin integrity by avoiding pressure on heel,
dorsum of foot, fibular head or malleolus
Halter Traction
• Indication: cervical spondylosis
Halter Traction
• Observe for pain and pressure
near ears, mandibular joints,
chin and occiput
• May protect skin with thin
foam padding
• Encourage male patient to
shave
• Remove traction for meals
and hygiene is allowed
Pelvic Traction
Indication: prolapsed lumbar intervertebral disc
Bryant’s Traction
Indication: fracture of the femur in children
< 3 years old, B.W < 30 lbs
Bryant’s Traction
• Apply bilaterally with hip flexed 45 degrees
and legs in extension
• Ensure skin integrity and non-adhesive straps
and wraps that do not impair neurovascular
status
• Ensure buttocks are elevated 1-2 inch from
mattress
Skeletal Traction
• Indication
– fracture shaft of femur
– fracture acetabulum
Assure that there is no
external rotation of the leg
as it may put pressure on
the peroneal nerve
Extra padding at the ischial ring
Pin tract checked and dressed daily
•The padding to the Pearson
attachment should end just before
the heel
•A footplate should be added for
support and to prevent footdrop
Active range of motion exercise
of the knee joint
90o- 90o skeletal traction
Olecranon pin traction Calcaneum pin traction
Halo traction
• Indication
– fracture or dislocation of cervical vertebrae
Special Consideration
• Select a halo-ring which allows 1-1.5 cm clearance
• The ring must be placed below the equator of the skull to prevent cephalad displacement
• Ring should be sterile otherwise the pins will be contaminated when passing through the ring into the skull
• Have patient gently close eyes and relax the forehead
Location of Pin Sites
• Two anterior pins are symmetrically placed in the
frontal bone groove superior and lateral to the
supra-orbital ridge
• Posterior , the pins are positioned posterior and
superior to the external ear
Skull Tong
Traction force recommended for
levels for C-spine injury
Level Min (kg) Max (kg)
1st 2.3 4.5
2nd 2.7 4.5-5.4
3rd 3.6 4.5-6.8
4th 4.5 6.8-9
5th 5.4 9-11.3
6th 6.8 9-13.5
7th 8.1 11.3-15.8
Orthopaedic Appliance
- Upper Limb
Arm Elevator
Arm Board
Arm Sling Arm sling (Triangular bandage)
Shoulder Immobilizer
Figure of Eight
90o-90o Elevation
Orthopaedic Appliance
- Lower Limb
Thomas Splint Elevation
Braun’s Frame
Abduction Pillow
Hi-lo chair
Anti- rotation boot
Gutter splint
AFO
Knee Immobilizer
(post-op)
Knee extension splint
Weight relieving calipre
Spinal Orthosis
Function
• To relieve pain
• To support weakened or paralyzed muscles and
unstable joints
• To immobilize the vertebral column in the best
functional position while healing occurs
• To prevent the occurrence of deformity or correct
deformity
Foam collar
Thomas collar
Moulded polythene
cervical orthosis
(Philadelphia neck collar)
SOMI Brace
Milwaukee Brace
(CTLSO)
Halo-Body Jacket
Knight brace
soft lumbar corset
Electric Immobilizer
Elbow crutches
Quadripod Stick
Walking frame
Walking Aids
Walking Aids
• Gutter, rollator
Gutter Frame
Rollator
2-wheel Gutter Frame
Pressure Ulcer Prevention
Pressure Reducing Support Surface
• Device lower tissue interface pressures, but do not consistently maintain interface pressures below capillary closing pressure in all positions , on all body locations.
• Static device
– Reduce pressure by spreading the load over a larger area e.g. foam, gel mattress
• Dynamic device
– Dynamic support surface- require a motor or pump and electricity to alternately inflate and deflate air cells e.g. alternating pressure air mattress
Pressure Relieving Support Surface
• Device consistently reduce tissue interface
pressure to a level below capillary closing
pressure in any position and in most body
locations
• E.g . Low-air-loss bed
Heel Protector
Sheep skin Silicon Mattress
Silicon gel pad
Ripple Bed
Low-air-loss bed
Turning and tilting bed