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Fracture and dislocations-management, closed-reduction, care of cast, open-reduction

MEDICAL MANAGEMENT OF FRACTURES

1)      REDUCTION

Reduction of a fracture (“setting” the bone) refers to restoration of the fracture fragments to anatomic alignment and rotation. Either closed reduction or open reduction may be used to reduce a fracture. The specific method selected depends on the nature of the fracture; however, the underlying principles are the same. Usually, fracture is reduced as soon as possible to prevent loss of elasticity from the tissues through infiltration by edema or hemorrhage. Before fracture reduction and immobilization, the patient is prepared for the procedure; permission for the procedure is obtained, and an analgesic is administered as prescribed. Anesthesia may be administered. The injured extremity must be handled gently to avoid additional damage.

a) CLOSED REDUCTION

Closed reduction is accomplished by bringing the bone fragments into apposition (ie, placing the ends in contact) through manipulation and manual traction. The extremity is held in the desired position and applies cast, splint, or other device. Reduction under anesthesia with percutaneous pinning may be used. The immobilizing device maintains the reduction and stabilizes the extremity for bone healing. X-rays are obtained to verify that the bone fragments are correctly aligned. Traction (skin or skeletal) may be used to effect fracture reduction and immobilization. Traction may be used until the patient is physiologically stable and able to withstand surgical fixation.

 A cast is a rigid external immobilizing device that is molded to the contours of the body.

Purposes of a cast are

  • to immobilize a body part in a specific position and to apply uniform pressure on encased soft tissue
  • to immobilize a reduced fracture
  • to correct a deformity
  • to apply uniform pressure to underlying soft tissue
  • to support and stabilize weakened joints

 TYPES of cast

  1. Short arm cast:Extends from below the elbow to the palmar crease, secured around the base of the thumb. If the thumb is included, it is known as a thumb spica or gauntlet cast.
  2. Long arm cast:Extends from the upper level of the axillary fold to the proximal palmar crease. The elbow usually is immobilized at a right angle.
  3. Short leg cast:Extends from below the knee to the base of the toes. The foot is flexed at a right angle in a neutral position.
  4. Long leg cast:Extends from the junction of the upper and middle third of the thigh to the base of the toes. The knee may be slightly flexed.
  5. Walking cast:A short or long leg cast reinforced for strength.
  6. Body cast: Encircles the trunk.
  7. Shoulder spica cast: A body jacket that encloses the trunk and the shoulder and elbow.
  8. Hip spica cast:Encloses the trunk and a lower extremity. A double hip spica cast includes both legs.

CASTING MATERIALS

Nonplaster

Generally referred to as fiberglass casts, these water-activated polyurethane materials have the versatility of plaster but are lighter in weight, stronger, water resistant, and durable. They consist of an open-weave, nonabsorbent fabric impregnated with cool water-activated hardeners that bond and reach full rigid strength in minutes. Nonplaster casts are porous and therefore diminish skin problems. They do not soften when wet, which allows for hydrotherapy. When wet, they are dried with a hair drier on a cool setting; thorough drying is important to prevent skin breakdown. They are used for nondisplaced fractures with minimal swelling and for long-term wear.

Plaster

The traditional cast is made of plaster. Rolls of plaster bandage are wet in cool water and applied smoothly to the body. A crystallizing reaction occurs, and heat is given off (an exothermic

reaction). The heat given off during this reaction can be uncomfortable that is informed to the patient he does not become alarmed. The crystallization process produces a rigid dressing. The speed of the reaction varies from a few minutes to 15 to 20 minutes. After the plaster sets, the cast remains wet and somewhat soft. It does not have its full strength until it is dry. The plaster cast requires 24 to 72 hours to dry completely, depending on its thickness and the environmental drying conditions. A freshly applied cast should be exposed to circulating air to dry and should not be covered with clothing or bed linens. A wet plaster cast appears dull and gray, sounds dull on percussion, feels damp, and smells musty. A dry plaster cast is white and shiny, resonant, odorless, and firm.

When the cast is dry, the nurse instructs the patient as follows

  • Move about as normally as possible, but avoid excessive use of the injured extremity and avoid walking on wet, slippery floors or sidewalks.
  • Perform prescribed exercises regularly, as scheduled.
  • Elevate the casted extremity to heart level frequently to prevent swelling.
  • Do not attempt to scratch the skin under the cast. This may cause a break in the skin and result in the formation of a skin ulcer. Cool air from a hair dryer may alleviate an itch.
  • Cushion rough edges of the cast with tape.
  • Keep the cast dry but do not cover it with plastic or rubber, because this causes condensation, which dampens the cast and skin. Moisture softens a plaster cast.
  • Report any of the following to the physician: persistent pain, swelling that does not respond to elevation, changes in sensation, decreased ability to move exposed fingers or toes, and changes in skin color and temperature.
  • Note odors around the cast, stained areas, warm spots, and pressure areas. Report them to the physician.
  • Report a broken cast to the physician; do not attempt to fix it.

POTENTIAL COMPLICATIONS OF CAST

• Compartment syndrome

• Pressure ulcer

• Disuse syndrome

b) OPEN REDUCTION

Some fractures require open reduction. Through a surgical approach, the fracture fragments are reduced. Internal fixation devices (metallic pins, wires, screws, plates, nails, or rods) may be used to hold the bone fragments in position until solid bone healing occurs. These devices may be attached to the sides of bone, or they may be inserted through the bony fragments or directly into the medullary cavity of the bone. Internal fixation devices ensure firm approximation and fixation of the bony fragments.

2)      IMMOBILIZATION

After the fracture has been reduced, the bone fragments must be immobilized, or held in correct position and alignment, until union occurs. Immobilization may be accomplished by external or internal fixation. Methods of external fixation include bandages, casts, splints, continuous traction, and external fixators. Metal implants used for internal fixation serve as internal splints to immobilize the fracture.

3)      MAINTAINING AND RESTORING FUNCTION

Reduction and immobilization are maintained as prescribed to promote bone and soft tissue healing. Swelling is controlled by elevating the injured extremity and applying ice as prescribed. Neurovascular status (circulation, movement, sensation) is monitored. Isometric and muscle-setting exercises are encouraged to minimize disuse atrophy and to promote circulation. Participation in activities of daily living (ADLs) is encouraged to promote independent functioning and self-esteem.

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