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