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Case Report

Closed plaster treatment of severe compoundinjuries e A report and revisit

Pankaj Kumar*

Consultant Orthopaedic and Spine Surgeon, Apollo Reach Hospital, Karimnagar, Andhra Pradesh 505001, India

a r t i c l e i n f o

Article history:

Received 26 October 2012

Accepted 17 May 2013

Available online 10 June 2013

Keywords:

Crush injuries

Treatment

POP

* Tel.: þ91 (0) 9618123678 (mobile).E-mail addresses: drpankaj06@yahoo.co.i

0976-0016/$ e see front matter Copyright ªhttp://dx.doi.org/10.1016/j.apme.2013.05.014

a b s t r a c t

A crushed injury of limb was treated with closed plaster method and elaborating the

treatment protocol and follow-up. We should look behind the old treatment method again.

Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved.

1. Introduction 2. Principles uponwhich themethod is based

The closed method has been known for nearly a century, and

the principles upon which it is based were known to Hippo-

crates, who stated that rest and immobilisation are of capital

importance in the treatment of wounds.

Billroth1 used plaster of Paris fixation with a window over

the wound and a no dressing. Ollier2 was the first to enclose

the wound completely in plaster. He treated 60 cases by his

occlusive method in the FrancoePrussian War, and described

his results in 1872. In 1881, Morisons3 of Newcastle-on-Tyne

strongly advocated large, firm dressings for wounds, to be

undisturbed for three to four weeks.

The closed treatment of wounds is based on sound prin-

ciples. The technique is exact and attention must be paid to

every detail if success is to be assured.

n, drpankaj06@gmail.com2013, Indraprastha Medic

A. Excision and surgical toilet: Primarily the object of early

excision of dead and devitalised skin, muscle, fascia etc, is

to get beyond the depth of penetration of bacteria and in

addition to remove dead tissue which would form an ideal

nidus for organisal growth. Dead muscle especially is an

ideal culture medium for the gas gangrene organisms. The

excision, thus, must be thorough and wide. The necessity

for removal of accessible foreign bodies, bits of cloth, etc.,

is obvious. Generally speaking, wounds seen up to 8 h of

infliction may be excised. When obvious infection is

already present, provision for drainage only should be

made, and no formal excision should be carried out.

B. Drainage: All parts of the wound must be left with free

access to the surface for the evacuation of discharges, and

.al Corporation Ltd. All rights reserved.

a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 1 3 4e1 3 6 135

there must be complete freedom from tension in the

wound. Wide openings, with “saucerisation”, and efficient

packing with Vaseline gauze, so as to form a conical pack,

fill these requirements. Tubes and sutures should not be

used.

C. Immobilisation: This is essential for healing of fractures,

for repair of injured soft tissues, and for prevention of

pain. Plaster of Paris, applied, including the joint above and

below the wound is the best form of fixation.

No window is cut over the wound, as “window oede-

ma”occurs, and healing is delayed. Trueta and Barnes4 have

proved experimentally that bacteria and certain toxins

(including tetanus toxin) are absorbed from wounds into the

blood-stream via the lymphatics only. They are not absorbed

when the lymphatics are obstructed or when the limb is

completely immobilised in plaster. They have also shown that

flow of lymph from a limb is increased by movement, heat,

massage and oedema. All efforts in wound treatment, there-

fore, must be directed to the reduction of lymph flow from the

limb. Complete immobilisation by means of a well fitting

plaster and prevention of oedema by a vaseline pack. No

window in the plaster, adequate local drainage, and elevation

of the limb, effectively.

3. Contraindication

The method is not to be used:

A. When a vascular lesion is present or when the circulation

of the limb is in doubt. Gas gangrene organisms flourish in

dead or poorly nourished muscles. These cases must he

observed or a few days before applying plaster.

B. When there is any suspicion of true gas gangrene. If there

is the slightest doubt about the significance of gas bubbles

or any anxiety about the state of nutrition of the limb, it is

better not to use the closed plaster.

C. When there is somuch contusion and crushing of the limb

that all devitalised tissue cannot possibly be excised and

there is risk of extensive necrosis subsequently,

D. In cases of severe multiple injuries, e.g. wounds of hu-

merus and chest, or of femur and abdomen, where a

plaster would interfere with the wounds on the trunk.

E. When extensive spreading cellulitis, e.g. Streptococcal or

anaerobic (B.welchii), cellulitis is present, plaster applica-

tion should be deferred until this has settled down.

4. Case report

A 7 years boy reported to the emergency department with his-

tory of playingnear parking,whendriver started the carhis one

leg trapped inside thewheel of car and in hurry somebody tried

to pull his leg from the wheel of car. While pulling he got this

severe injuries. His leg and foot were crushed. He reported to

emergency department within 3 h of injuries with active

bleeding from wound and with hypovolemic shock. When we

examined the limb there was almost complete degloved lower

two third right leg with visible anterior two third of tibia and

fibula and anterior part of all bone of foot, visible all tendon

includingall around theankle joints and tendonanterior to foot

was lost,withnovisiblepulsationbut soleof footwas intact and

there was active bleeding from muscles. We corrected the

shock, and X-ray showed there were multiple fractures of

metatarsal bone and without fracture of tibia and fibula. We

planned for wound debridement and K-wire fixation of bone

and coverage of bone by the help of plastic surgeon. According

toplastic surgeon it isnotpossible tocover theopenvisiblebone

of leg and foot in one sitting. So he said, you try some other

means of modalities. Then we opt for closed plaster treatment

because we don’t have any other choice. We did wound

debridement and K-wire fixation of metatarsal of foot and

above knee POP cast application. K-wire removed at 6 weeks

interval. Initial first month we had removed the old cast and

reapplication POP cast at one week interval and from second

monthfifteenday interval orwhenPOP is soakedwhichever are

early. After three month bone was completely covered with

granulation tissue. We did skin grafting. In follow-up, wound

was completely healed and child was completely walking with

near normal gait at the end of two years of follow-up (Fig. 1).

5. Discussion

Crush injuries of the limb are serious and can be difficult to

manage. These complex injuries often involve soft tissue and

osseous structures. Potentially devastating complications and

long-term sequelae can occur if these injuries are under-

estimated or mismanaged. Due to the high morbidity associ-

ated with crush injuries, prompt and meticulous care is

essential. Orr5 strongly condemns the closure of a wound

communicating’with a compound fractureon the grounds that

in compound fractures generally it is virtually impossible to be

sure that a wound is clean and to close it up (by suture) after no

matter how thorough amechanical cleansing and anantiseptic

sterilization is usually to close up no little potential infection.

Trueta6 advocates the closed method of treating war frac-

tures. Thiswas carried out by himas follows: (a) Excision of the

all dead muscle and haematomata, (b) Reduction of the frac-

ture, (c) Drainage of the wound with absorbent gauze, (d)

Immobilization of the limb in plaster of Paris. By this means

every possible attempt is made to prevent the growth of or-

ganisms from themoment ofwounding. The surgeon thenhas

muchbetter opportunity to eliminate infectionby excisionand

debridement, even if undertaken well over the 8-h period.

It is realised that a better line of treatment would have

been immediate reduction of the fracture with a K-wire and

coverage of woundwith appropriate soft tissue. Unfortunately

no such apparatus was available. Closed plaster method

depended for its efficiency on physical and physiological ef-

fects rather than its influence on the flora.

This article reviews the characteristics of plaster of Paris

and re-introduces the concept of tissue adaptation in

response to the application of plaster of Paris splints and

casts. Clinical examples of the use of plaster of Paris are dis-

cussed. Such question should lead the reader to use plaster of

Paris splinting or casting more often to solve clinical problem.

It is recommended that a consultation with colleagues should

Fig. 1 e a and b: Preoperative photograph. c and d: during POP application period. e :photograph during skin grafting. f and g:

after 3 months of skin grafting. h and i: photograph at the end of 2 years.

a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 1 3 4e1 3 6136

always be held if it is decided to amputate a limb. One may

conclude by stressing again the basic principle of adequate

drainage and complete immobilisation in using the closed

method; the importance of selecting cases and bearing mind

the few contraindications to the closed plaster meticulous

attention to detail in technique and after e care.

Conflicts of interest

The author has none to declare.

r e f e r e n c e s

1. Billroth. Clinical Surgery. London: The New Sydenham Society;1881.

2. Ollier L. Congress medical de France; 1872:192.3. Morison Rutherford. Surgical Contraindication. vol. 1, pp 2

and 11.4. Trueta J, Barnes. British Med J. 1940 July 13:46.5. Orr Vinnett. J Bone Joint Surg. 1928;10:605.6. Trueta j. Treatment of War Wound and Fractures. Hamish

Hamilton; 1940.

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