Plaster casts have been widely used in the treatment of fractures for many years, but medicine does not stand still and modern alternative materials to the usual plaster splint are increasingly being used - plastic (polyurethane) casts, which are used in our clinic.
Complaints about plaster from ordinary people are not difficult to understand.
A heavy bandage greatly restricts movement. If it is placed on your leg, it is impossible not only to get to the hospital without outside help, but sometimes even to get to your own kitchen. Plaster chips that break off from the inside of the cast cause itching and discomfort, and in some cases allergic reactions. The plaster also gets wet, so taking a shower after a fracture is a real adventure: you have to wrap the plastered area with polyethylene or literally wash yourself in parts. However, all this is temporary discomfort, which can be easily tolerated. Doctors have much more serious claims. Recently, one can increasingly hear that traditional plaster application can lead to re-displacement of the fracture. It is extremely difficult to monitor whether the bones are healing correctly under the bandage: the plaster does not transmit x-rays well. And with its prolonged use on the damaged area, blood circulation is disrupted, muscles, joints and tendons suffer. Chained and immobilized, they hardly work, so they gradually begin to lose their functions. It is no coincidence that after the cast is removed from the leg, patients still limp for some time. Local osteoporosis is also a frequent complication: without load, the bones near the fracture become less strong.
That is why specialists have recently used techniques in which gypsum is used to a minimum or replaced with other materials.
Some types of dressings
- Removable-fixed. It is used when necessary to monitor the wound and carry out regular therapeutic manipulations at the fracture site.
- Finished. It differs from the longitudinal-circular one by the presence of a “window”. For example, at the site of the fracture, atheroma removal with a laser or another procedure must be urgently performed. In this case, this area is left open.
- With a stirrup. A metal pad that is added when a cast is applied to the leg: thus, the structure is protected from damage when walking.
Plaster technique in outpatient traumatology practice
Content
S.B. Korolev, N.B. Tochilina, S.P. Vvedensky
teaching aid
N. Novgorod, 2006
A doctor of any specialty in his practice will definitely meet with a person who has been placed in a plaster cast. This publication provides general rules for applying the most common plaster casts in outpatient practice. Particular attention is paid to complications caused by the plaster cast and ways to prevent them.
The educational and methodological manual is intended for students, interns and clinical residents studying in the specialties of surgery, traumatology, etc.
The purpose of this publication is the general rules of application technique for treatment in outpatient practice.
Observations from the Nizhny Novgorod Research Institute of Traumatology and Orthopedics indicate that the cause of most serious complications in fractures of the radius in a typical location and ankle fractures are errors in the correct application of plaster casts and lack of monitoring of the patient in the coming days. The available monographic literature devoted to this problem is not available to students.
The proposed educational manual provides brief historical information about the use of plaster casts and highlights the role of N.I. Pirogov in disseminating and improving the method of applying plaster casts. The indications for applying bandages and all the practical aspects of the plastering technique are described in detail.
Particular attention is paid to the need for physician supervision of patients with a plaster cast, the possibility of complications and their prevention.
The authors hope that the educational manual will facilitate the mastery of plaster technology by students, interns and clinical residents and will help prevent complications associated with incorrect application of bandages and untimely control.
One of the principles of fracture treatment is immobilization of the associated fragments for the entire period of callus formation. A modern plaster cast that meets this requirement has come a long way historically. Since the time of Hippocrates, various splints and hardening dressings have been used to immobilize a broken bone. Medicine knows various substances that have the property of hardening at different rates: gypsum, glue, liquid glass, starch, cottage cheese, gelatin, paste, etc. Many centuries ago, Arab doctors used clay to treat fractures.
The chief surgeon of the French army of Napoleon I, Larrey, recommended soaking the dressing material with a mixture of protein, lead vinegar and camphor alcohol. In the 19th century, the method of making fixed bandages from fabric, paste and cardboard, proposed by the Belgian doctor Setana, became widespread in the 19th century. One of the first successful attempts to use plaster of Paris to fix fractures was made by the Russian surgeon Karl Hubenthal (1815). He poured a plaster solution over the injured limb, first on one side, then on the other, and secured the resulting plaster cast with bandages. Our other compatriot, V.A. Basov (1843) proposed placing the limb in a box with alabaster and moistening it with water. The Dutch doctors Matthiessen and Loo used strips of cloth rubbed with dry plaster, which were moistened with water as the bandage was applied.
Plaster casts became truly widespread in the treatment of fractures during the time of Nikolai Ivanovich Pirogov, who generalized previous experience and proposed a simpler and more reliable method of applying a plaster cast, publishing in 1854 the book “Mapped alabaster plaster cast in the treatment of simple and complex fractures and for transporting the wounded to the battlefield." Method N.I. Pirogov was as follows: the limb was wrapped in rags, a plaster solution was prepared, shirt sleeves, underpants, stockings were folded into 2-4 layers and dipped into the plaster slurry.
These strips, soaked in plaster, were stretched “on the fly,” smoothed out on both sides by hand and applied longitudinally to the limb (splints), strengthening them with transverse strips so that one overlapped half of the other. In the area of the joints, the stripes were laid out in the form of figure eights. This bandage followed the contours of the limb and was very durable. Thus, N.I. Pirogov was the first to propose the application of longitudinal and circular bandages made of fabric impregnated with liquid gypsum.
Subsequently, Goff, Kalot and Lorenz developed a technique for applying plaster casts using gauze bandages. Recently, synthetic hardening materials have appeared that are used in medicine, but gypsum remains an unsurpassed quickly hardening material that has excellent plastic and hygienic properties.
The method of one-stage manual closed reduction with fixation of fragments with a plaster cast is historically the oldest among modern methods of treating fractures, but has not lost its significance to this day. A significant change in the lifestyle of a modern person, along with guaranteed benefits, unfortunately, has led to a significant increase in injuries, in the structure of which severe injuries requiring treatment in specialized clinics are increasingly occupying a place. The development of surgery in recent decades has led to the emergence of new, high-tech methods in traumatology that help save and return such victims to life and work. Along with this, some patients with minor injuries require outpatient care in a trauma center, where patients not only with soft tissue damage, but also with fractures are treated and treated.
The method of choice for treatment of outpatients with fractures should be considered conservative using plaster casts. This method has its advantages - non-invasiveness, low trauma, low cost, and with appropriate indications, skillful technique and careful monitoring of the patient throughout the entire period of immobilization with a bandage, it gives the desired result: the fracture heals, the patient returns to his previous lifestyle. Like any other method, conservative treatment of fractures by applying plaster casts has its drawbacks and can cause serious complications that disable the patient.
Plaster casts are widely used in traumatology after unstable osteosynthesis, in the treatment of patients with fractures using skeletal traction as a subsequent immobilization, and in pediatric orthopedics. As an independent method of treatment, plaster casts are indispensable in outpatient practice in the treatment of patients with fresh fractures of the bones of the hand, forearm, supracondylar fractures of the shoulder in children, bones of the foot, fractures of the ankles, some fractures of the tibia, in other words, in the treatment of such fractures that, - firstly, they can be reduced simultaneously manually or with the help of any devices, and secondly, after reduction of which the fragments will be securely held by a plaster cast.
Contraindications for applying a plaster cast are local infectious complications: phlegmon, purulent leaks, anaerobic infection, gangrene, ischemic limb disorders.
The application of large plaster casts (thoracobrachial, Deso, coxitis) to elderly patients is also contraindicated.
The main material for the production of gypsum used in medicine is a mineral widespread in nature - gypsum stone, which is calcium sulfate dihydrate (CaSO4 2H2O). Gypsum stone is slowly calcined at a temperature not exceeding 130 ° C, during which it partially loses water and turns into calcium sulfate hemihydrate, or the so-called burnt gypsum, which, after mixing with water, has the ability to form an excellent plastic material that quickly hardens in its given form. This property is used in medical practice for applying bandages.
Gypsum should be stored in dry rooms in closed containers, as it tends to absorb moisture from the atmospheric air and at the same time loses its ability to quickly harden.
There are different grades of gypsum. Good grades of gypsum have a somewhat yellowish tint, which depends on proper calcination. Uncured gypsum has a snow-white color. To make a good dressing, the plaster should feel like flour to the touch, without lumps or grains. To do this, it is sifted through a fine sieve. To assess the quality of gypsum, a test is carried out: take a little gypsum and mix it with the same amount of warm water until the consistency of sour cream is obtained. It should be noted that the lower the water temperature, the slower the gypsum hardens. Typically, water is taken at a temperature of 30-35°C. The resulting slurry is spread in a thin layer on a plate and the hardening time of the gypsum is determined (it should be 3-5 minutes). If the hardening of the gypsum occurs much later, then the quality of the powder is assessed as low and it is considered unsuitable for use. The plaster plate is then removed from the plate and broken into pieces. Bad plaster breaks and crumbles easily.
Currently, plaster casts are made from plaster gauze bandages. There are machine methods for making plaster bandages and a manual method that allows you to get a better quality plaster bandage.
How is plaster removed?
The technique for removing the plaster cast, regardless of the location of the fracture, is almost the same. It is important to be careful not to cause pain to the patient. If the bandage is thick, it is cut with special scissors or files in two steps. Sometimes, in order to remove the plaster, it is first soaked in a solution of sodium chloride. Doctors note that it is still worth removing the plaster under the supervision of a doctor, since there is a high probability of damage to the injured area. After removing the bandage, the skin is washed with soap and water and treated with an antiseptic. The plaster cast is removed like a regular bandage, and the top layer is gradually unwound. The bandages that secure the splint are cut using Cooper scissors and beak-shaped forceps. There are also special plaster scissors, but the places that will be cut must first be marked on the bandage.
Functionality and versatility
Functional treatment of fractures with a shortened plaster cast is an original method that has been used for a long time. But it requires a certain qualification from the doctor; in our clinic we quite widely use this method of casting on different parts of the body for fractures. Most often it is used for fractures of the ankle, radius, metacarpal, and metatarsal bones. The bandage in this case can be made from either ordinary plaster or plastic, or modeling hard and soft plastic plaster at the same time. But they apply it in a special way.
Traditionally, traumatologists try to fix the damaged area as firmly as possible. For example, when a tibia is fractured, a bandage is often applied from the knee to the toes. In functional treatment, the doctor acts differently: a very small area directly above the fracture is placed in the cast. The nearby joints remain free.
Materials for applying splints
The classic material for making such bandages is plaster bandage. It is a cotton gauze strip impregnated with plaster.
Modern immobilization dressings consist of polymer materials that imitate gauze strips and contain multiple through holes like a mesh. Polymer splints are not inferior in strength to plaster casts, but have much less weight. In addition, these materials can be of different colors.
Plastic generation or alternative to conventional plaster
A good alternative to good old plaster is now considered, for example, plastic gypsum. It can also be called artificial or polymer - the essence does not change. This is a special material that the doctor first dips into water and then applies to the broken segment according to a certain pattern. After some time, the bandage dries, fixing the damaged area.
In general, the principle of operation is not very different from the traditional one. However, there are a number of advantages: plastic bandages are 4-5 times lighter than plaster ones - it is much easier to move when wearing them. In terms of strength, they are in no way inferior to plaster, so you don’t have to worry that broken bones will move or heal incorrectly.
Plastic plaster is not afraid of moisture, you can take a shower with it. This bandage also “breathes.” Unlike standard plaster, it allows oxygen to pass through to the skin and, on the contrary, evaporates to the outside. As a result, itching and irritation occur much less frequently.
In addition, plastic plaster looks neater than regular plaster. If you accidentally get it dirty, you can simply wipe the bandage with an important tissue.
However, with all the advantages, this material has its own nuances. A doctor who knows its characteristics should work with this type of plaster, since the material hardens very quickly and self-application of this plaster by the patient is unacceptable! And in some cases it is even dangerous. In addition, removing an artificial bandage is more difficult than a traditional one. You cannot cut artificial plaster with scissors—special tools are required. Our clinic has quite experienced doctors, so applying a plastic plaster cast, after consulting a doctor, will not take much time.