Closed Reduction and Casting of Fractures
Closed reduction can happen when a fracture has not been exposed to the air (a compound fracture) and can be done even if internal fixation is going to be done later. Closed reduction uses traction and the “reversal of the mechanism of injury” in order to put the bones back into alignment as much as possible. Splints can be used so that swelling is allowed to happen—this cannot happen if the fracture is cast right away. Ideally, the joint above the fracture and the joint below the fracture need to be immobilized so the fracture ends don’t separate again.
Splints are often used to allow for swelling of the fracture in the immediate days after the fracture. They can be prefabricated or custom-made using splinting materials. Fluffy cotton is often used between the splint and the skin to prevent chafing of the skin from the splint.
There are several types of splints:
• “Bulky” Jones Splints. This is used on the lower extremity and involves lots of fluffy cotton batting and a splint applied on the posterior aspect of the lower leg and the bottom of the foot. An ACE wrap is used to keep the splint attached to the leg. Another way to do it is to wrap the splint from medial to lateral around the malleoli of an ankle fracture, for example.
• Sugar tong splint. This is an upper extremity splint used for forearm fractures. A U-shaped splint is applied to the front and back of the forearm, wrapping the U shape around the elbow.
• Coaptation splint. This is used for humeral fractures. The splint wraps around the elbow and comes up in a U shape with the ends at the axilla and onto the shoulder on the other side.
• Ulnar gutter splint. This is a splint that just goes along the ulnar bone, wrapping the splint around the bone and ACE wrapping the splint around the forearm.
• Volar/Dorsal Splint. This is a splint that extends from the base of the fingers to the elbow on the back or front of the forearm and is ACE wrapped around the forearm.
• Thumb Spica Splint. This wraps around the thumb and extends down to the wrist or distal forearm for thumb fractures.
• Posterior Slab ankle splint. This goes around the back of the ankle from the toes to behind the knee.
• Posterior slab (thigh). This goes from the buttocks down to below the knee and is ACE wrapped onto the thigh.
• Knee immobilizer. This is a preformed splint that wraps around the knee with stays that keep the knee held in minimal flexion.
• Cervical collar. This can be soft or hard and keeps the neck still in a neutral position.
• Pelvic Binder. This involves a lot of padding that binds the pelvis so the bones do not move.
The goal of casting is prolonged, semi-rigid immobilization of the fracture without damaging soft tissue. It involves Padding with a minimum of two layers around the affected area and more padding around bony prominences. Cold water is not used to immerse the casting material because it won’t set up fast and hot water burns the skin. Room temperature water is used instead. Two to four inch wide casting material is used for the upper extremity and 4-6 inch wide plaster is used for the lower extremity and humerus. Fiberglass has advantages and disadvantages. It doesn’t mold as well as plaster but is lighter and more resistant to breaking down than plaster. It is also stronger than plaster.
Short Leg Cast
It should support the metatarsal heads and the ankle should be completely neutral once the cast is set. The knee should be flexed when the cast is applied and the toes should wiggle freely. There should be a buildup of material on the base of the foot if this is to be a walking cast. Fiberglass is much more durable than plaster. Extra padding should be at the bottom of the foot.
Above the Knee Cast
This is a long leg cast that is applied first below the knee and then above the knee. The knee is flexed 5-20 degrees flexion. There should be molding around the proximal part of the femur so rotation of the leg is kept stable. There is extra padding around the kneecap for comfort.
Short and long arm casts
The knuckle joints should always be free in this type of cast and it should not go past the palmar crease in the palm of the hand. The thumb and the fifth finger should be able to touch each other. There should be even pressure around the entire length of the cast. There should be no tight molding except in the area of the palm of the hand.
There can be loss of reduction of the fracture when the cast is applied so the fracture doesn’t heal appropriately. There can be pressure necrosis even if the pressure is applied to the skin too much for as little as 2 hours. If a cast is too tight, it can be slit along one end for a 30 percent reduction in pressure of the extremity or cut in two places for a reduction of pressure of 60 percent. If the padding is cut through, there is less pressure on the casted area.
Burns can happen if the cast is put on with hot water. This is rare with fiberglass, which sets at a lower temperature. There can also be cuts and burns that occur when the cast is cut off. There can be thrombophlebitis or a pulmonary embolism due to keeping the limb still, especially with lower extremities. Stiffness of the joints are also possible after prolonged immobilization.
Traction is sometimes used to help keep the bones from foreshortening during healing. Usually only about ten pounds of traction are used to keep the bones at maximum length. It can help in the operating room to aid reduction of the fracture. Skin problems can occur in the elderly who receive traction. Buck’s traction is a type of traction of the lower extremities that involves wrapping a dressing around the calf and foot, attaching a weight to the end of the bed. It helps relieve pain in hip fractures and some fractures in children.
Skeletal traction is more powerful than traction around the skin. About twenty percent of body weight can be pulled on the lower legs with this type of traction. Pins are inserted inside the bone using local anesthesia down to the bone. Pins or wires can be used to attach the traction to bone.
One type of traction is called tibial skeletal traction in which the pin is placed behind and just below the tibial tubercle. A sterile dressing is applied to the skin to keep the area well protected from germs. Pelvic, acetabular and many types of femur fractures have femoral skeletal traction applied. The pin is placed medial to lateral in order to avoid hitting nerve bundles. The pin goes through the distal part of the femur and traction is then applied.
Calcaneal skeletal traction is used for ankle fractures that can’t be reduced as well as some distal tibial fractures. The pin is placed from medial to lateral in the calcaneus.
The Gardner-Wells Tongs are a type of traction that is used in cervical fractures. Pins are placed near the ear and the traction is applied to reduce cervical fractures using 5-10 pounds of force. It may be the only thing used for correction of a cervical spinal fracture. There can be respiratory compromise or problems with the pins. A halo ring is fit around the head, attached to the pins. Pin sites can be above the eyebrow or behind and above the ear. About 6-8 pounds of force are used for this type of fracture. Pins are tightened every 24 hours.
I’m Ed Smith, a Sacramento personal injury lawyer with much experience in fractures and their complications. Call me anytime for free, friendly advice at 916-921-6400 in Sacramento and 800-404-5400 Elsewhere in California.
Member of Million Dollar Advocates Forum.