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Immobilization
of Fractures
Initial immobilization of
injured extremities prevents further damage before definitive stabilization can be
achieved. Movement of sharp fracture ends can cause serious soft tissue trauma and even
skin puncture, converting a closed injury to an open one. Immobilization also facilitates
transport of patients and relieves pain, thus decreasing the need for narcotic analgesics.
Injuries located about or distal to the knee or
elbow can usually be immobilized initially with splints. A wide variety of splints are
available, including those made of preformed aluminum or plastic, those made of inflatable
clear plastic, and those that are easily adjustable with Velcro closures. Plaster of Paris
(calcium sulfate hemihydrate) splints molded individually for patients provide the best
support. All splints are best applied by an assistant while the injured extremity is held
with gentle longitudinal traction.
Most injuries of the shoulder, upper arm, and
elbow can be immobilized effectively with a sling. If needed, the arm can be kept close to
the body with an elastic wrap or swath. Hip fractures can be immobilized by careful
positioning with pillows or by light skin traction.
Casts are used
to control the alignment of a fracture while it heals. Traditionally, casts are made of
rolls of stiff muslin impregnated with plaster of Paris. Inexpensive and easy to mold,
plaster is often used for initial casts and for those that need frequent changing. Plaster
casts are relatively heavy, deteriorate with excessive or prolonged use, and weaken when
wet. Cast materials made of polymeric resins and fiberglass are stronger, stiffer, and
half as heavy as plaster casts. Water will not weaken the cast itself, but if the
underlying padding becomes wet, the cast must be changed to prevent skin maceration.
To provide complete immobilization, the cast
must extend across one joint above and one joint below the fracture site. Thus for a
distal radial fracture, the cast should extend from above the elbow to just proximal to
the metatarsal joint; however, because joint stiffness is a major problem in the elderly,
the cast is often made to end below the elbow, allowing joint motion.
Patients with casts must be given detailed
instructions. For the first 24 to 48 h after the injury, the extremity should be elevated
to prevent swelling. Rhythmic flexion and extension of the fingers or wiggling of the toes
should be encouraged to facilitate venous return. The patient should immediately report
progressive or unrelenting pain, pressure, or numbness in the affected extremity because
swelling within an unyielding circular cast can cause enough pressure to stop tissue
perfusion, creating compartmental syndrome (see below).
Traction is
used in the elderly only when no satisfactory alternative exists, eg, if the fracture is
too fragmented for a cast or surgical stabilization or if the patient's medical condition
will not permit surgery. Complications of traction include pressure sores, deep venous
thrombosis, pulmonary embolism, depression, disorientation, loss of appetite,
deconditioning, atelectasis, and pulmonary infection. Meticulous, aggressive nursing care
is required during traction.
Skin traction is particularly hazardous in the
elderly. Its only indication is to provide temporary, gentle restraint of the extremity
for comfort. Such traction is applied using foam boots or carefully wrapped moleskin
strips, a sash cord, and a pulley with a 5-lb weight. A weight > 5 lb should never
be used. Vigilant monitoring is required. The strong, prolonged traction needed to
maintain bone alignment must not be applied with skin traction but rather with the use of
skeletal pins. The proximal tibia is the most common traction pin site for femoral and
acetabular fractures.
Operative stabilization
of fractures can offer dramatic benefits in elderly patients. Those with hip fractures,
for instance, can usually begin walking within days after surgery. The risks of surgery
are small compared with those of prolonged traction, especially for leg fractures.
Despite these advantages, surgical treatment of
most fractures should be postponed until acute medical problems can be corrected. Only
fractures associated with such limb-threatening conditions as impending compartmental
syndrome, neurovascular compromise, or open wounds require urgent treatment. Furthermore,
some conditions are relative contraindications to surgery. Sepsis could lead to infection
of the operative site and prohibits the use of metallic implants. Severely osteoporotic
bone has poor mechanical properties, and the hardware used in operative stabilization will
become displaced if it does not have a secure hold in the bone.
A deep postoperative wound infection, a serious
complication, frequently requires removal of all implanted hardware, prolonged daily
dressing changes, and weeks of IV antibiotics. Prophylactic antibiotics can reduce the
incidence of postoperative infections in hip fracture patients to about 1%. A
cephalosporin is the agent of choice; an appropriate regimen is cefazolin 1 gm given IV
during the hour before surgery, followed by 1 gm q 8 h for the next 24 h.
Ambulatory Aids
Orthotic and
self-help devices. |
Fig.101:
Fig.102: