UNIVERSITY OF CAPE TOWN'S ORTHOPAEDIC DEPARTMENT...when standing. Collar and cuff The collar and cuff is made from sponge. It has a loop that goes around the neck and another loop

LEARNING INNOVATION VIA ORTHOPAEDIC NETWORKS

UNIVERSITY OF CAPE TOWN'S ORTHOPAEDIC DEPARTMENTEditor: Michael Held

Casting of fracturesAuthor/s: Michael Held Reviewed by: Anria Horn, Nick Kruger, Duncan McGuire Students: Lisa Coetze, Tarryn Kawalsky, Anna Notten

Learning ObjectivesBy the end of this chapter, students will be able to:

1. Understand the basic principles of reduction 2. Apply a POP

IntroductionFractures should be reduced and then splinted, preserving joint movement as much as possible. Reduction is unnecessary with: • non-displaced fractures • when displacement doesn’t matter • when reduction is unlikely to be

successful (needs referral)Complications of casting include: a tight cast causing obstruction to blood flow or pressure sores, or a loose cast leading to loss of reduction.

Plaster of Paris (POP) is made of calcium sulphate hemihydrate that has been applied to a mesh. When water is added to it, it sets and hardens by releasing heat and water (i.e. an exothermic reaction). The setting of the POP is therefore dependent on the temperature of the water (cold – slow, warm – fast). If the water is too hot this exothermic reaction can burn the skin.

What you will needStockinette (if available), orthopaedic wool roll 15cm wide and 500cm long, plaster slabs, water at room temperature, gloves, scissors/POP saw, alcohol swabs, analgesia, sedative,

and monitoring equipment.

Sizes of plaster used• Upper arm and forearm (10cm), • Wrist (10cm), • Thumb and fingers (7.5cm), • Thigh and legs (15cm), • Ankle and foot (15cm)

How to apply a POP1. Sedation:2. Clean the skin, apply dressing to zany

wounds and remove all rings.3. Mainly use traction and then reduce

residual angular or rotational deformity (see reduction section)

4. Apply stockinette without wrinkles. This avoids the limb hairs being caught in the plaster, it facilitates perspiration, and also makes removal of the POP easier. Fold the loose ends back of the stockinet over the POP once it has been applied.

5. Apply uniform thickness of ortho wool with 50% overlap

6. Protect bony prominences with extra ortho wool.

7. Soak plaster roll in water until all air bubbles of the POP subside

1. Pick up the end of the plaster and gently squeeze water out

2. Apply slabs or circular POP3. Hold the limb in the correct position4. Mould the plaster and its edges around the

limb, ensuring the surfaces are all smooth. The plaster will take 3-5 minutes to dry, (It will properly dry after 24 hours)

5. Avoid leaving ‘thumb’ dents in the POP which can cause pressure sores. Use flat palms to mould.

6. Reinforce the weak spots, particularly around joints which need to be immobilised

7. Repeat radiographs

After cast application• Check for comfort and excessive

tightness• Check neurovascular function• Elevate the limb wherever possible• If the cast is too tight, split it at 2 opposite

sides (i.e. medial and lateral) using a POP saw or sizors, and stabilise with a crepe bandage. Provide instruction to patients for plaster care

• Exercise joints free of the plaster as soon as possible

Plaster care instructionsProvide oral and written instructions in an understandable, non-technical language:

• Raise the limb (to the level above the heart, if possible)

• Exercise all joint and muscles surrounding the immobilised limb frequently

• Keep the cast or splint dry at all times.

Cover the limb with a plastic bag when showering or bathing.

• Do not scratch the skin under the cast as this may introduce a source of infection

• Allow the cast to dry for 24 hours before applying any weight on it or resting it on a hard surface

• Elevate the injured part for 24–48 hours

Instruct the patient to return to the health clinic immediately if:

1. The cast or splint becomes wet, soft or broken

2. There is increasing pain3. There is numbness or tingling, or

difficulty moving the fingers or toes4. The patient notes a change in skin colour

of the extremities5. The cast or splint develops a foul odour

How to remove a cast safely• Using an oscillating electric POP cast

saw make two longitudinal cuts along opposing surfaces of the cast, avoiding areas where the bone is prominent.

• The saw cut is progressed by ‘dabbing’’ it along, not sliding as this may scratch the skin.

• Once the vertical cuts have been made, loosen the cast with a plaster spreader.

• Complete the division of the plaster and the padding with plaster scissors, with careful attention not to injure the underlying skin.

• The saw is noisy and may scare the patient especially children. Reassure them by demonstrating the saw on your palm before approaching the POP.

• An alternative method to the saw is to soften the plaster by soaking it in water for 10–15 minutes and then removing it simply like a bandage

References 1. WHO. Casts and Splints. Available

from: https://www.who.int/surgery/publications/s16376e.pdf

2. Solomon L, Warwick DJ, Nayagam S. Apley’s concise system of orthopaedics and fractures. CRC Press; 2005 Mar 31.

3. McRae R, Esser M. Practical fracture treatment. Elsevier Health Sciences; 2008 Mar 6.

Modified images• Closed fracture. Available from: https://

smart.servier.com/smart_image/bone-fracture-11/

Learning ObjectivesBy the end of this chapter, students will be able to:

1. Understand the basic types of slings

IntroductionThere are 3 types of slings used for upper limb injuries in orthopaedics:1. Shoulder immobiliser2. Collar and cuff3. Broad arm sling

Shoulder immobiliserThis is most commonly prescribed after an injury or surgery to a shoulder or an elbow. The shoulder immobiliser comes pre-packaged in various sizes. The part of the sling that the forearm rests in is made of material and it encloses the forearm with velcro straps. There is a strap that extends from the forearm component around the neck and back onto the forearm component. There is an optional strap that goes around the body to prevent the arm moving away from the body. This strap is usually only used when the intention is to not allow shoulder abduction.

When applying, position the elbow in the corner of the shoulder immobiliser. Ensure that the strap at the back of the neck is adequately padded so that the sling is comfortable. For a properly positioned sling, the forearm should be in a horizontal position parallel to the ground when standing.

Collar and cuffThe collar and cuff is made from sponge. It has a loop that goes around the neck and another loop through which the hand passes. The arm is supported with the wrist resting in the loop. The loop around the wrist should be loose enough that the patient is able to put in and take out their hand themselves.

The collar and cuff is very easy to apply and is cheaper than the shoulder immobiliser. It does not support the elbow, so in certain conditions where elbow support is required, the shoulder immobiliser may be better. Examples of this

2.5 SlingsAuthor: Duncan McGuire

Broad arm sling Triangle sling Collar and cuff

include clavicle fractures and acromioclavicular joint injuries. The collar and cuff is ideal for conditions where there is a plaster of paris cast, brace or bulky bandage around the upper arm or elbow, where the bulkiness would interfere with the elbow fitting into the shoulder immobiliser. Examples include humerus fractures that are immobilised in a U-slab and where there is a bulky bandage around the elbow following surgery.

Editor: Michael Held

Conceptualisation: Maritz Laubscher & Robert

Dunn - Cover design: Carlene Venter Creative

Waves - Developmental editing and design:

Vela and Phinda Njisane

About the bookInformed by experts: Most patients with

orthopaedic pathology in low to middle-income

countries are treated by non-specialists. This

book was based on a modified Delphi consensus

study with experts from Africa, Europe, and

North America to provide guidance to these

health care workers. Knowledge topics, skills,

and cases concerning orthopaedic trauma and

infection were prioritized. Acute primary care

for fractures and dislocations ranked high.

Furthermore, the diagnosis and the treatment of

conditions not requiring specialist referral were

prioritized.

The LION: The Learning Innovation via

orthopaedic Network (LION) aims to improve

learning and teaching in orthopaedics in

Southern Africa and around the world. These

authors have contributed the individual chapters

and are mostly orthopaedic surgeons and

trainees in Southern Africa who have experience

with local orthopaedic pathology and treatment

modalities but also in medical education of

undergraduate students and primary care

physicians. To centre this book around our

students, iterative rounds of revising and

updating the individual chapters are ongoing,

to eliminate expert blind spots and create

transformation of knowledge.

Reference: Held et al. Topics, Skills, and

Cases for an Undergraduate Musculoskeletal

Curriculum in Southern Africa: A Consensus

from Local and International Experts. JBJS.

2020 Feb 5;102(3):e10.

Disclaimers Although the authors, editor and publisher of

this book have made every effort to ensure that

the information provided was correct at press

time, they do not assume and hereby disclaim

any liability to any party for any loss, damage,

or disruption caused by errors or omissions,

whether such errors or omissions result from

negligence, accident, or any other cause.

This book is not intended as a substitute for the

medical advice of physicians. The reader should

regularly consult a physician in matters relating

to his/her health and particularly with respect

to any symptoms that may require diagnosis or

medical attention.

The information in this book is meant to

supplement, not replace, Orthopaedic primary

care training. The authors, editor and publisher

advise readers to take full responsibility for their

safety and know their limits. Before practicing

the skills described in this book, be sure that

your equipment is well maintained, and do not

take risks beyond your level of experience,

aptitude, training, and comfort level.

The individual authors of each chapter are

responsible for consent and right to use and

publish images in this book. The published work

of this book falls under the Creative Commons

Attribution (CC BY) International 4.0 licence.

Acknowledgements Michelle Willmers and Glenda Cox for their

mentorship.