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ORTHOPAEDICS ANDTRAUMATOLOGY


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10Traction

Lower-limbtractionLimb traction is useful for reducing and immobilizing femoral shaft fractures;supracondylar and intercondylar fractures of the femur; condylar fractures of theupper end of the tibia; grossly infected or contaminated fractures of the tibia;and severe fractures of the ankle mortise with subluxation or dislocation or both.Neglected dislocations of the hip and knee, gross deformities and displacementsdue to traumatic, infectious, or rheumatoid conditions of the hip and knee, anddeformities after poliomyelitis can all be corrected by continuous traction.The most popular form of continuous traction of the extremities is skeletal trac-tion (through bone). Skin traction, provided by straps of adhesive plaster appliedon the skin, is generally confined to use on children, but can be helpful whentransporting adults to hospital. On anaesthetic limbs, only skeletal tractionshould be used.

Skin tractionEquipment See tray and equipment forSkin traction,Annex 1 , page 191

Technique Sedate the patient (anaesthesia is unnecessary). Clean the limb with soap andwater, and dry it. Prepare the skin with an antiseptic solution, preferablymethylated spirit, and let it dry. If a commercial traction set (complete withadhesive tapes, traction cords, spreader bar, and foam protection for the malleoli)is not available, improvise the apparatus as described below.Open a roll of adhesive strapping on a clean dry table and spread it with theadhesive surface up. (Use a size appropriate to the size of the patient; for anadult, a 7.5-cm wide, non-elastic tape is usually suitable.) For above-knee trac-tion, measure a length of strapping that is twice the length of the limb from thegreater trochanter to the sole of the foot (Fig. 10.1A). Add an extra 35-40 cm toaccommodate the spreader and to leave enough space (10-15 cm) between thesole and the spreader to permit movement at the ankle. For below-knee trac-tion, the length of strapping should be measured from the tibial condyles(Fig. 10.1B). For the treatment of compound fractures, traction should beapplied just distal to the site of fracture and the strapping should be cut accord-ingly.Place a square, wooden spreader of approximately 7.5 cm (with a central hole) inthe middle of the length of strapping that you have spread on the table. Cutanother length of strapping about 35-40 cm long and centre it on the spreaderwith the adhesive surface down. The spreader is now sandwici~cd etween thetwo strappings (Fig. 10.1C).


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Orthopaedics and traumatology

Fig. 10.1 . Skin traction. Measuring the limb to determine length of strapping required(A); levels of tibial condyles, malleoli, and Achilles tendon (B); sandwiching the spreaderbetween two strappings (C); applying strapping to the leg while protecting the malleoli(D);bandaging over the strapping E);attaching traction (F ,G).


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Traction

Holding the patient's ankle and foot, pull the limb steadily, elevating it fromthe bed. Instruct an assistant to hold the spreader with a loop of strapping pro-jecting 10-1 5 cnn beyond the sole of the foot. Apply the strapping to the medialand lateral sides of the limb, stil l elevated and held in moderate traction. Protectthe malleoli, Achilles tendon insertion, and the head and neck of the fibula byplacing strips of felt or cotton-wool padding under the strapping at these sites(Fig. 10.1D). For above-knee traction, the adhesive strapping should extendproximally to thl: groin on the medial side and to the greater trochanter on thelateral side. To avoid causing deformity due to external rotation, place the lateralstrapping slightly posterior, and the medial strapping slightly anterior to themid-lateral and mid-medial lines, respectively. Ensure that the strapping liesflat on the surface of the limb. Do not cover the anterior border of the tibia orencircle the limb with strapping.Now apply a crepe or ordinary gauze bandage firmly over the strapping begin-ning 2-5 cm proximal to the malleoli (Fig. 10.1E). Continue bandaging up thelimb, over the strappings, up to the groin (or as appropriate to the level of trac-tion). Elevate the end of the patient's bed and attach a traction cord through thespreader with the required weight (Fig. 10.1F,G); this should normally not ex-ceed 5 kg.

Contraindications Do not apply skin traction to a limb with abrasions, lacerations, $cers of theskin, loss of sensation, impending gangrene, atrophic skin, or peripheral vasculardisease. Skin traction is also contraindicated in the treatment of marked overrid-ing of fracture fra ~~ me nt sr of gross, long-standing deformities.

Complications Possible complications include allergic reaction to the adhesive material (usuallyzinc oxide); blister formation or excoriation of the skin from the strapping slip-ping; pressure sores over the malleoli; and common peroneal nerve palsy. Most ofthese complications can be avoided by correct application of the adhesive strap-ping. The most ~mportant ause of common peroneal nerve palsy is lateral rota-tion of the l im b, resulting in compression of the nerve at the upper end of thefibula. Avoid this by keeping the patient's knee joint moderately flexed (up toloo).

Skeletal traction The best site for inserting traction pins is the metaphyseal region of a maturebone. The specific sites recommended for pin insertion, in order of frequency ofclinical use, are described below (measurements are given for adults).Proximal tibia (Fig. 10.2A,B): insert the pin approximately 2 cm distal to thetibial tubercle and 2 cm behind the anterior border of the tibia, from the lateralside to avoid the {common eroneal nerve.Distal tibia (Fig. 10.2A,B): insert the pin from the lateral side approximately4 cm proximal to the most prominent part of the lateral malleolus. Place the pinproximal to the ankle mortise, parallel to the ankle joint, and midway betweenthe anterior and posterior borders of the tibia. There will be resistance as the pinpasses through both cortices of the tibia anterior to the fibula.Calcaneum (Fig. 10.2C): insert the pin 4.5 cm inferior and 4 cm posterior to thetip of the medial malleolus, from the medial side to avoid damaging the pos-terior tibial artery and nerve or entering the subtalar joint.Insertion of the pin through the distal end of the femur is not recommended atthe district hospital.


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Ortho~ aedics nd traumatoloav

Fig. 10.2. Skeletal traction through bone. Sites for insertion of Steinmann's pins in theproximal and distal tibia (A , B) and in the calcaneum (C); Steinmann's pin, introducer,chuck, and stirrup (D); infiltrating tissues with local anaesthetic (E); making an incisionand inserting the pin (F-I); dressing skin wound s, attaching the stirrup, and covering theends of the pin U,K); applying traction, with the leg supported by a sling (L).


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Traction

Equipment See tray and equipment for Skeletaltruction,Annex 1 , page 190.

Technique Skeletal traction is most commonly applied through Steinmann's pins(Fig. 10.2D) inserted under local anaesthesia. The patient should be supine. Pre-pare the skin with antiseptic. Infiltrate the skin and soft tissues down to thebone with 1% lidocaine (Fig. 10.2E). Make a small stab incision in the skin andintroduce the pi11 through the incision horizontally and at right angles to thelong axis of the limb. Proceed unti l the point of the pin strikes the underlyingbone (Fig. 10.2F,G). Ideally the pin should pass through the skin and subcu-taneous tissue, but not muscles.Pins are best inserted with a T-handle (Fig. 10. 2H) or hand dri ll. Use a malletonly to make a start in the cortex and always hammer gently. Advance the pinuntil it stretches the skin of the opposite side and make a small release incisionover its point (Fig. 10.21).Dress the skin wounds separately with sterile gauze (Fig. 10.25). Attach a stirrupto the pin, and lubricate with sterile petrolatum jelly the site where it rotates onthe pin. Cover the ends of the pin with guards (Fig. 10.2K), and apply traction(Fig. 10.2L).As a rough guide, '110-'17 of the body weight provides adequate traction,though this will also depend on the degree of displacement of the fracture andthe musculature of the limb. Traction must always be opposed by counter-traction, which can be provided by the weight of the patient's body, by elevationof the appropriate end of the bed some 10-20 cm, or by placing a Thomas splintagainst the root of th e limb (see pages 93-94).When a Thomas splint is used, traction will be more comfortable if the l imb issupported by pillows or pads, which also prevent posterior sagging of the frac-ture fragments.

Complications Infection of the pin track is a common complication. Clinically the skin is in-flamed; the wounds are moist; percussion over the bone elicits tenderness; andthe pin becomes loose. If the infection is not controlled by repeated dressingsand antibiotics, r(t.move he pin and employ an alternative method of traction. Ifthe bone is osteoporotic and the traction too heavy, the pin will cut through thebone. Accurate insertion of the pin avoids complications from damage to theneighbouring neurovascular bundles and from penetration into a neighbouringjoint. Prevent possible stiffness in the joint or contractures of tendons by repeat-ed active and assisted exercises.

Skull tracticonSkull traction forms an important part of conservative treatment for conditionssuch as pyogenic or tuberculous infections of the craniovertebral region or thecervical spine. This type of traction can provide rest to the cervical spine; correctrecent deformities; or reduce dislocations or subluxation in traumatic, infectious,and rheumatoid conditions. Cervical fractures or fracture dislocations, irrespec-tive of cord involvement, are also best treated this way.

Equipment See tray and equipment for Skulltruction, Annex l , page 191.


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B C

Fig. 10.3 . Skull traction. Cone callipers with spanner (A); marking the scalp with twolines (B); sites for insertion of Crutchfield callipers(*) nd Cone callipers(X)(C).

Technique As an alternative to head-halter traction, which is painfully uncomfortable forthe patient, Crutchfield or Cone callipers (Fig. 10.3A) are easier to apply andmore comfortable. Prepare the patient's scalp and mark it with two lines: onefollowing the midline (sagittal), the other crossing it to join the mastoid pro-cesses (Fig. 10.3B,C). Wi th the middle of the instrument poised over the mid-line, place the callipers on the transverse line to mark the points of entry(Fig. 10.4A,B). Plan to insert Crutchfield callipers proximal to the parietal emi-nence and Cone callipers distal to the parietal eminence on the transverse line,5-6 cm above the external meati (Fig. 10.3C).After infiltrating the selected sites with 1% lidocaine, make stab wounds in thetransverse line and deepen them to the bone (Fig. 10.4C,D). Use a special drillbit with a protective shoulder to make a hole 3-4 mm deep in the outer table ofthe skull, avoiding penetration of the inner cortex (Fig. 10.4E-G). Insert thepoints of the callipers and tighten them to give a secure hold on the bone(Fig. 10.4H,I). Dress the wounds with strips of sterile gauze and apply appro-priate traction ('110 - 17 of the body weight, i.e., about 5-13 kg) (Fig. 10.45);be sure to check and tighten the callipers, as necessary, after 1-2 days. The lowerthe level of the diseased area the heavier the traction required. After 2-7 days ofheavy traction, reduce and maintain it at 1-2.5 kg in adults.

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Traction

Fig. 10.4. Skull traction (continued).Marking sites for insertion of Crutchfield callipers(A , B); infiltrating the scalp with local anaesthetic (C); making a small wound anddeepening it by drilling into the bone (D, F, G) ; drill bit (E); inserting the points of thecallipers and applying traction (H-J).


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11Plaster technique

Preparation of plaster bandagesPlaster of Paris (POP) bandages are available ready-made from suppliers andthese are far superior to the home-made variety. The popular length is 250 cmand the usual widths used are 15 cm (6 inches) and 7.5 cm (3 inches). Because ofthe higher cost of the ready-made POP bandages, many hospitals in developingcountries still prepare their own.

Equipment See equipment for Makingplaster bandage, Annex 1 , page 190.Technique For a POP bandage, employ a dry, cotton gauze (muslin) bandage 500 cm longand 15 cm wide, with an open weave (20-24 strands to 2.5 cm). Place the rolledbandage on a dry table with a smooth concrete or metal top. Unroll the bandageso that one section is spread evenly across the table and, with gloved hands,apply the plaster powder (anhydrous calcium sulfate or gypsum) evenly to thesurface of the bandage (Fig. 11.1A). Gently but firmly rub the powder into themesh of the cotton bandage. Once this is done, carefully roll up the powderedlength of bandage and begin the same process again with a new section of thebandage (Fig. 11 lB). Continue until the whole bandage is impregnated with

Fig. 11 .1 . Making a plaster bandage. A cotton gauze bandage is unrolled as plasterpowder is applied to the surface (A);rolling the powdered gauze (B).

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Plaster technique

plaster powder. The weight of an average plaster bandage should be 85-90%plaster. This plaster bandage can be used immediately or stored in a dry place forfuture use.To prepare a plaster slab, unroll the required length of plaster bandage andsuperimpose layer upon layer to the necessary thickness (6-12 layers). For a nar-row slab, first make a thin slab and then fold it along its length.

Removal of tight rings and banglesAlways remove bangles or rings from an injured l imb prior to any operative pro-cedure or application of a POP bandage.

Equipment Equipment includes oil or soap, and an Esmarch bandage for limbs or a cottontape for fingers.

Technique Often the object can be coaxed from the limb or digit if it is well lubricated withoil or soap. Should this fail, the l imb or finger can be compressed by exsanguina-tion. To compress a finger, wind a cotton tape (approximately 0.5-1 cm wide) orthread from the tip of the finger up to the ring (Fig. 11.2A,B). Run the looseend of the tape under the ring, and then gently unwind the tape or thread bypulling the loose end (Fig. 11.2C-F). As the tape is unwound, the ring shouldgradually slip off the end of the finger. The same technique can be used to re-move bangles.

Application of plasterEquipment See equipment for Application ofplaster, Annex 1, page 187.Technique First examine the area to which the plaster is to be applied; identify the bonylandmarks and take measurements for the preparation of plaster slabs(Fig. 11.3A,B). Drain and dress any skin blisters, and otherwise clean the skin ofthe area with soap and water, dry it, and clean it again with methylated spirit.To avoid the serious complications that can result from pressure, pad all plasterswith a uniform thickness of 0.5 cm of cotton wool (Fig. 11.3C,D). Add an extralayer of padding to protect the bony prominences, especially in areas with noskin sensation, or if the patient is thin .

Prepare any plaster slabs that you will require (Fig. 11.3E-G). Then soak a plas-ter bandage (or a plaster slab, if this is to be applied first) in a deep, wide-mouthed pail filled with water at room temperature (Fig. 11.3H). For a largeplaster, such as a shoulder or hip spica, fill two or more pails with water to avoiddelay during application. Lower the plaster bandage into the water until it iswell covered (Fig. 11.31). Leave it undisturbed until air bubbles cease to rise,showing that it is saturated with water. Gently pick up the ends of the bandagewith both hands and lightly squeeze it, pushing the ends together withouttwisting or wringing (Fig. 11.35).The plaster is now ready to be applied.While applying the plaster, ask an assistant to hold the relevant part of the bodysteady in the correct position so that ridges do not form inside the plaster(Fig. 11.3K). Throughout application, work rapidly and without interruption,rubbing each layer firmly with the palm so that the plaster forms a homogeneousmass rather than discrete layers. Mould the plaster evenly around the bonyprominences and contours. (Remember that the "hold" of the plaster will not befrom its tightness but from its fit.) Leave 3 cm of cotton wool padding at theupper and lower margin of the cast to protect the skin against friction.


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Orthooaedics and traumatoloav

Fig. 11.2 . Removal of a tight ring from a finger. Winding cotton tape or thread from thetip of the finger and passing the loose end under the ring (A-D); pulling the loose end ofthe tape or thread to remove the ring (E, F).


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Plaster technique

Fig. 11.3 . Application of plaster bandages. Identifying the bony landmarks (A); takingmeasurement (B); applying a padding of cotton wool (C , D); measuring plaster bandageand superimposing and trimming several layers for a plaster slab (E-G); soaking theplaster bandage (H, I).

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Orthouaedics and traumatoloav

Fig. 11.3. Application of plaster bandages (continued). Squeezing the bandage (J);applying the plaster bandage to the forearm over the cotton wool (K); applying andmoulding a plaster slab (L , M); folding the margins of the plaster after applying a furtherlayer of plaster bandage (N,0);pplication of plaster cast completed (P ,Q).


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Plaster technique

To form a complete plaster cast, apply a light, uniform layer of plaster bandageby winding i t round the padding. Wi th the first layer, apply one or more plasterslabs, carefully moulding each one with the palm of the hand (Fig. 11.3L,M).Follow this with a few layers of plaster bandages wound round lightly withouttension. Just before the plaster sets, gently fold over the sharp margins of thecast, leaving the cotton padding exposed (Fig. 11.3N,O) . A turn of plaster ban-dage will secure the padding over the cast. Continue moulding the plaster untilit sets, the time for this depending upon the quality of the plaster bandage andthe ambient temperature. When the plaster begins to stick to your hands, it is agood indication to stop.The table below gives the number and width of plaster bandages required for theaverage adult patient for various standard plaster casts. With ready-made band-ages, fewer are required.

Type of cast Width of bandages Number of bandagesAbove elbow 10-1 5 cm (4-6 ches)Below elbow 10 cm (4nches)Below knee 15 cm (6 nches)Up to the gron 15 cm (6 nches)1'/z h p sp ica 15-20 cm (6-8 nch es)Shoulder spca 15-20 cm (6-8 nches )

Plasterslab If major soft-tissue swelling is expected, apply a padded posterior plaster slabextending approximately two-thirds of the length of the limb. Whenever thereis doubt about the circulation in a limb, apply only a plaster slab. A slab is alsoadequate protection for fractures or dislocations around the elbow, hand, andfingers. Mould the plaster slab to the limb and hold it in position with wetgauze bandages.An alternative method is to split a full plaster lengthwise down to the cottonwool with a sharp knife or scalpel immediately after application, before it hastime to dry (Fig. 11.4A). Wi th a plaster spreader (Fig. 11.4B) or stout scissors,spread apart the split plaster edges some 5-10 mm (Fig. 11.4D) . Split the un-derlying cotton wool with a pair of blunt, angled scissors (Fig. 11.4C) until theskin can be felt through the gap in the plaster along the entire length(Fig. 11.4E). Secure the split plaster in place with a firmly applied, 7.5 cm-wide,elastic bandage (Fig. 11.4F).

Partiallypaddedplaster When a plaster is changed some weeks after the initial trauma or operation,further swelling of the limb is unlikely to occur and it is safe to apply the newcast over a single layer of stockinet, with padding only over the bony promi-nences.

Instructions to be given Give the patient (or hislher relatives) clear oral and written instructions to reportto the patient back to the hospital if there is any impairment of the circulation. Issue the pa-tient with a standard instruction card in a language that helshe can understand.The instructions should be as follows:1. Do not cover the plaster, but let it dry in the sun or hot air (a wet plastertends to break). Do not walk on a walking-plaster until it is fully dry.2 . Keep the l imb in plaster elevated when you are at rest.3. Exercise all free joints of the affected limb, especially those of the fingers (in-cluding the knuckles) and toes, shoulder, elbow, and knee. Move each joint(with assistance, if necessary) regularly and frequently during the day, untilnormal movements are possible without pain.


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Fig. 11.4. Splitting a plaster cast. Splitting a newly applied plaster cast with a scalpel(A); a plaster spreader (B) or stout scissors (D) are used to open up the gap in th e plastercast; dividing the underlying cotton wool with a pair of blunt, angled scissors (C, E) andthen holding the split plaster with an elastic bandage (F).

4. Sleep on a mattress placed on a hard bed or floor.5 . Report to hospital as soon as possible if the plaster is damaged in any way or

if it is loose. Report to hospital immediately if pain from the plaster inter-feres with sleep.

6. If symptoms of poor circulation develop (such as fingers or toes becomingswollen, blue, painful, or stiff) raise the limb and exercise the affected part. Ifafter half an hour there is no improvement and if it is not possible to returnimmediately to hospital, ask someone to split the plaster along its entirelength. First soak the limb in water to soften the plaster and then cut it witha knife, or saw through the plaster, including the cotton wool. Temporarilyhold the split cast in place by wrapping it with a length of cloth about8-10 cm wide and 1 m long. Make arrangements to return to hospital assoon as possible.


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Plaster technique

Complications associated with immobilizationin plasterMost of the problems related to POP plasters are in fact caused by improper ini-tial application of the cast.

Pressure sores Sores can result from localized pressure on bony prominences, from ridge form-ation on the inner surface of the cast, or from forcing foreign bodies between theplaster and the limb. They may occur anywhere, but common sites are over theanterior superior iliac spine, sacrum, malleoli, and the dorsum of the foot orankle. Frequently the sequence of events is as follows: for several days the patientcomplains of persistent localized discomfort; the complaint is ignored and thesymptoms pass off; by this time the tissues under pressure have become anaes-thetic and sloughing has already commenced; soon the overlying cast becomesstained, and the accumulated discharge and secretions become offensive. Neverneglect the signs suggestive of a sorealways cut a window in the plaster.Treat pressure sores by cutting a hinged window in the plaster at the suspectedsite using a small, angled plaster saw (Fig. 11.5A-C). If there is ulceration, cleanand dress it, but if no serious lesion is detected, just fill the window with a uni-form pad of cotton wool. In all cases, replace the piece of plaster and apply a firmbandage over it to prevent oedema of the unsupported soft tissues presentingthrough the window (Fig. 11.5D,E).

Fig. 11.5. Cutting a window in a plaster cast. Cutting with a small, angled plaster saw(A-C); the ulcer is cleaned and dressed, the plaster window piece is replaced, and the areais bandaged (D,E).


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Fig. 11.6. Removing a plaster. Cutting and spreading the plaster using plaster shearsand a spreader (A-C); soaking a plaster before removing it (D,E).


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Plaster technique

Oedema distal Some degree of distal oedema is inevitable around injuries to the ankle or wrist.to the plaster Cast Oedema as a result of injury disappears within 2-3 days with elevation of thelimb and repeated active exercise of the joints not in plaster. If oedema does notdisappear in 2-3 days, the probable cause is a tight plaster. In such cases, spli tthe plaster along its full length and cut the padding or stockinet down to thesurface of the skin. Prise the plaster open 1-2 cm along its entire length. Elevatethe limb and continue active exercises.

Skin blistering The skin under a plaster inevitably becomes dry and scaly because the discardedand dermatitis epithelium is not washed off. Rarely the skin is susceptible to plaster allergy anddermatitis develops. In hot weather, particularly when there is eruption ofprickly heat (miliaria), staphylococcal infection of hair follicles and sweat glandsmay supervene and, if ignored, can lead to a severe painful and purulent derma-titis. Antihistamines, systemic antibiotics, and elevation of the limb should re-lieve most of the symptoms within 48 hours. In severe cases, or if there is noimprovement, adopt an alternative method of treatment or apply a new plasterwith extra padding.

Gangrene Gangrene after a fracture is usually the result of damage to the vascular supply ofthe injured limb, but careful recording of capillary circulation (and pulse when-ever possible) both before and after the application of plaster should avoid thetragic occurrence of gangrene or Volkmann's contracture from a tight or unpad-ded splint.

Plaster removalEquipment See equipment for Removingplaster,Annex 1, page 190.

Technique The best place to cut a plaster is along its weakest or thinnest border(Fig. ll.6A). Avoid cutting through the plaster slab where it overlies the sub-cutaneous border of a bone. Use shears to cut through the plaster, starting at theedge, and then loosen the cast with a plaster spreader (Fig. 11.6A-C). Completethe division of the plaster and padding with plaster scissors. Under difficult con-ditions or if your patient is a frightened child, soften the plaster by soaking it inwater for 10-15 minutes and then remove it like a bandage (Fig. 11.6D,E), orcut it with a sharp scalpel or knife.


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Open fractures and tendoninjuries

Open fracturesClassification Open fractures are classified into three grades, with chances of infection beingthe highest in Grade 111:

Grade I fractures involve a clean wound of less than 1 cm in size.Grade I1 fractures involve laceration of skin and subcutaneous tissueand a wound of more than 1 cm.Grade I11 fractures involve extensive lacerations, avulsion of soft tissues,damaged muscles, nerves, and vessels, and comminution of bone frag-ments.

Treatment Wounds associated with Grade I fractures should be covered with a steriledressing after dkbridement, treatment thereafter being the same as for a closedfracture, though it may be prudent during wound healing to provide cover withantibiotics for 5-10 days. Patients with Grade I1 or Grade I11 fractures should bestarted on antibiotics immediately to cover a careful dkbridement to remove alldead and suspect tissue. A large wound may require a longer course of anti-biotics. Always administer tetanus toxoid to patients with open fractures.Treat concomitant joint injuries by wound toilet, closure of the synovium andcapsule with catgut, postoperative suction drainage, and preferably postopera-tive traction, with frequent, intermittent exercise of the joint above and belowthe fracture.

Wound closure Do not carry out primary closure in any cases of open fracture. On comple-tion of wound dkbridement, take a swab for bacteriological examination. Takeadditional swabs on the first and second inspections during follow-up. Inspectand dress the wound daily or as indicated depending on the discharge.Assess the condition of the wound 5-7 days after the initial operation. Close thewound at that time only if it is healthy. If the wound is not healthy, wait afurther 2-4 weeks and then close it by loose suture or by split-skin grafting (seepage 99). Wo und closure under tension wi th inadequate drainage is the commonest causeof ischaemia of the limb, and predisposes to uncontrollable anaerobic infection andextensive chronic osteomyelitis.

Stabilization of the fracture After wound dkbridement, stabilize the fracture by one of the followingmethods.Apply a well-padded, strong posterior plaster slab or a complete plastercast (split to prevent constriction, see pages 87 and 88) (Fig. 12.1A).


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Open fractures and tendon injuries

Fig. 12.1. Stabilization (immobilization)of fractures. A padded plaster slab (A); Thomassplints with and without slings (B, C); measuring the limb for selecting a splint of suitablesize (D-F); fixed skin traction in a Thomas splint (G); fixed skeletal traction in a Thomassplint (H); fixed skin traction in a Thomas splint reinforced with a plaster cast (Tobrukplaster) (I);stabilization with Steinmann's pins and a plaster castU,K).


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For the lower extremity, apply a Thomas splint of suitable size (Fig.12.1B-F), and skeletal or skin traction (Fig. 12.1G,H) ; if transportingthe patient to another hospital, further reinforce the splint with POPbandages applied around it and the limb (Tobruk plaster) (Fig. 12.11).Insert one, or preferably two, Steinmann's pins in the proximal anddistal fragments of the fractured bone and incorporate the l imb as wellas the pins in a padded plaster (Fig. 12.1J,K). Before application of theplaster, make sure that there is no dressing or bandage encircling thelimb tha t might act as a tourniquet.

Tendon injuriesSudden, excessive, unaccustomed, or uncoordinated strain can rupture appar-ently normal tendons, for example the Achilles tendon (which can ruptureduring jumping), the plantaris tendon, and the extensor attachment into theterminal phalanx of the finger (whose rupture causes mallet finger). Some ofthese closed injuries may be complications of epileptic fits. Direct, blunt injuriesover the Achilles tendon while in plantar flexion or over the rectus femoris ten-don while the knee joint is extended can also cause rupture.Closed tendon injuries in the middle-aged or elderly patient occur in degener-ated tendons. Any undue strain or even normal activity may rupture a tendonpartially or completely. Common sites are the tendons of the rotator cuff in theshoulder, the long head of the biceps, the rectus femoris tendon, and the ex-tensor tendons at the wrist in rheumatoid disease.Any tendon can be cut or torn in an open wound, but common sites are at orabove the wrist and in the palm and fingers. Tendons are most commonly sev-ered in deep, incised wounds, and less commonly by laceration.

Diagnosis Partial rupture causes tenderness over the injured tendon, and movements thatare still possible are painful. After complete rupture of larger tendons, a gap canbe felt when movement is attempted, and the belly of the muscle bunches upinto an abnormal lump or "ball" above the rupture. The absence of specificmovements in healed wounds of the finger and wrist also suggests tendon injury.If the joints become stiff, tendons that are still intact can be felt tensing underthe palpating fingers during movement.In all cases of open injuries over tendon sites, test each tendon individually forits specific action. For example, absence of flexion of the terminal phalanx indi-cates injury to the profundus tendon, while inability to produce plantar flexionat the ankle suggests injury to the Achilles tendon. Identify cut tendons duringwound dkbridement.

Treatment Partial rupture of tendons, whether degenerated or normal, requires no activesurgery. Rest the tendon in a relaxed position until the initial pain has subsided;Partial rupture then start rehabilitative exercises. Infiltration of the site with a few millilitres oflocal anaesthetic is occasionally indicated to relieve pain and give the patient theconfidence to start these movements.

Complete, closedrupture Complete, closed rupture of tendons, especially in the young, usually requiressurgical repair a t a higher level hospital. In the middle-aged or elderly patient,decisions must be made as to whether referral for further treatment is indicatedor whether the loss of function is compatible with the patient's daily activities.In cases of acute rupture of the Achilles tendon, extreme plantar flexion for 6weeks followed by a lesser degree of equinus for another 6 weeks will lead to a


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Ooen fractures and tendon iniuries

Fig. 12.2. Primary suture of a cut tendon. Inserting figure-of-eight suture (A-C);pulling the two ends of the suture (D); nserting a similar suture in the other end of thetendon (E); tying the sutures and burying the knots (F);suture is completed (G).

union sufficient for normal activities in most patients. Shoulder-cuff ruptures inthe elderly should be treated conservatively by rehabilitative exercises. Ruptureof the long head of the biceps may usually be left alone since it rarely causessignificant disability, but fresh cases of mallet finger should be treated bystraight splintage for 4-6 weeks (see page 123).

Op en injuries Open tendon injuries require surgical treatment, starting with wound dCbride-ment. Tendon repair then depends upon the site of the tendon injury and thetype of wound (contaminated or clean). Refer any patient with: a cut tendonassociated with a contaminated, lacerated wound; a cut flexor tendon on the ant-erior aspect of the wrist, palm, or fingers; or a cut tendon that cannot be clearlyidentified and sutured. Pending referral, keep the related joints mobile by pas-sive assisted exercises.

Repair of cut tendons Immediate repair of cut tendons by primary suture is appropriate at the districthospital only in cases of open injuries to: the flexor tendons in the forearm; theextensor tendons of the forearm, wrist, and fingers; the extensor tendons on thedorsum of the ankle and foot; and the Achilles tendon. Repair of divided fingerflexors within the synovial sheath requires meticulous surgery and should neverbe attempted at the district hospital.


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Equipment See tray for Minor operations, Annex 1, page 190. Equipment for Application ofplaster, Annex l , page 187,may also be required.

Technique The patient should be given a general anaesthetic with a muscle relaxant.After wound dkbridement, pass a loop suture (310 silk or nylon) on a straightneedle into the tendon through the cut surface close to the edge so that it em-erges 0.5 cm beyond, and construct a figure-of-eight suture, finally bringing theneedle out again through the cut surface (Fig. 12.2A-C). Pull the two ends ofthe suture to take up the slack, but do not bunch the tendon (Fig. 12.2D). Dealsimilarly with the other end of the tendon (Fig. 12.2E), and then tie the cor-responding suture ends to each other, closely approximating the cut ends of thetendon and burying the knots deep between them (Fig. 12.2F). Cut the suturesshort (Fig. 12.2G).

After-care Hold the repaired tendons in a relaxed position with suitable splintage for 3-4weeks.


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For details of the treatment of abdominal injuries, ruptured bladder, wounds ofthe face, and ocular trauma, see Cook, J. et al., ed. General surgery at the districthospital (Geneva, World Health Organization, 1988).

Vascular traumaInjury to the main limb arteries and veins may be open or closed. Open injuriesare easier to diagnose because of profuse bleeding from the wound in the vessel.If a vessel is completely divided, however, its ends retract and there is littlebleeding, although the circulation to the distal limb is usually compromised.Closed injuries are usually associated with fractures of the long bones and shouldbe suspected if there is distal ischaemia of an injured limb. The important clini-cal features of such ischaemia are pallor or discoloration of the foot or hand,severe pain, and absent or diminished distal pulses.Closed injury of the main vessels can also manifest itself by marked swelling ofthe limb in the region of the fracture, with or without a pulsating haematoma("false aneurysm"). The distal circulation is usually not compromised. Venousinjuries are generally less serious and rarely result in circulatory problems,though local swelling from the haematoma and distal swelling of the limb fromimpaired venous return often occur.In all cases of limb injury, be alert for any clinical features of injury to the mainvessels. Explore any suspect wounds near or overlying the main vessels, and iden-tify the vessels. Also explore closed l imb injuries when there is distal ischaemiaor marked swelling in the region of the fracture, again identifying the majorvessels to check for injury.

Equipment See tray for Min or operations, Annex 1 , page 190 , and add four bulldog clamps, aset of three Satinsky's clamps, and some fine rubber tubing.

Technique For vascular injuries, general anaesthesia is preferred. Make a long incision overthe wound or fracture site to allow a wide exposure of the main artery and vein.Profuse haemorrhage will indicate the location of the damaged vessel, unless it iscompletely divided. Both ends of a completely transected vessel should be li-gated. An incompletely divided vessel should be controlled above and below theinjury by light arterial clamps (for example, Satinsky's or bulldog) (Fig. 13.1C)or by lifting on ligatures or rubber tubing (Fig. 13.1A,B,D), and repair may beattempted by direct suture (Fig. 13.1E,F) or a vein patch. A bruised, bu t intactartery that no longer pulsates may have suffered a rupture of the lining withocclusion of the lumen. If referral to expert care is easy, close the wound looselyand transfer the patient for consideration of vascular grafting. If not, excise the


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Fig. 13.1. Vascular trauma. Controlling bleeding with rubber tubing (A , B, D); control-ling bleeding with light arterial clamps (C); suturing an arterial wound (E, F).

damaged segment of vessel between ligatures. If in doubt in cases of vascularinjury, arrest bleeding by direct ligature, close the skin loosely, and refer thepatient.Severe swelling of a limb, after crushing injuries or fracture, can compromise thecirculation, leading to ischaemic damage to the muscles and to Volkmann's is-chaemic contracture (see below). If the limb is markedly swollen, perform anadequate decompression fasciotomy as a matter of urgency. Make a long incisiondown the anterolateral surface of the l imb, through the deep fascia, allowing thetense muscle to bulge into the wound. Leave the wound open under dressings,and close it later by secondary suture or eventually by skin grafting.

Volkmann9s schaemiaVolkmann's ischaemia can occur as a complication of any fracture of the leg orarm involving a major artery. Its main features, as in any other acute ischaemia,


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are pain that is severe and agonizing on passive stretching (extension) of the fin-gers or toes; pallor of the digits with poor capillary circulation (sometimes re-sulting in a cyanosis or blotchy appearance of the skin) and an abnormally coldlimb; pulselessness, an important feature of vascular complication; paralysis,with muscle weakness and sensory deficit distal to the site of vascular damage;and tense and tender muscles as revealed by palpation.

Treatment Immediately remove all encircling bandages, leaving the posterior splint, whichshould not cover more than half of the circumference of the limb. The skin of thefront of the limb should be entirely visible. Carefully reduce any gross displace-ment of the fracture fragments, and then moderately elevate the swollen limb toencourage venous and lymphatic return. Straighten any acute flexion of the jointto prevent mechanical kinking of the artery. For the arm, a position of 20-70' offlexion is advised. Do not warm or heat the limb but keep it cool, especially in ahot environment, to reduce local tissue metabolic requirements. (See also sectionon vascular trauma, page 97.)

Split-skin graftingSkin is the best cover for a raw surface caused by trauma or burns. The recipientarea for the graft should have healthy granulation tissue with no evidence of in-fection.

Equipment See tray for Skin grafiing, Annex l ,page 191Technique The patient should be given a general anaesthetic.

The most commonly used donor site is the anterolateral or posterolateral surfaceof the thigh. First clean the selected donor site with antiseptic and isolate it withdrapes. Apply petrolatum or liquid paraffin (mineral oil) to lubricate the area.Hold the assembled skin-grafting knife (Humby) (Fig. 13.2A) in one hand andpress the grafting board against the patient's thigh (or alternative donor site)with the other hand. Instruct an assistant to apply counter-traction to keep theskin taut by holding a second board in the same manner. Cut the skin withregular back-and-forth movements while progressively withdrawing the firstboard ahead of the knife (Fig. 13.2B).After cutting a length of about 2 cm of skin, inspect the donor area: homo-geneous bleeding confirms that the graft is of split-skin thickness; exposed fatindicates that the graft is of full thickness, i.e., too deep, in which case youshould check the adjustment of the blade. As the cut skin appears over the blade,instruct an assistant to hold it gently out of the way with non-toothed dissectingforceps. Place the newly cut skin in saline and cover the donor area with a warmwet pack before dressing it with petrolatum gauze. Spread out the cut skin, withthe raw surface upwards, on petrolatum gauze (Fig. 13.2C).If a skin-grafting knife is not available, the graft can be taken with a razor bladeheld with straight artery forceps. Start by applying the cutting edge of the bladeat an angle to the skin but after the first incision lay the blade flat.Before applying the skin graft, clean the recipient area with saline. Wet the graftfrequently with saline to prevent it from drying out. Do not pinch it with in-struments. To graft a large piece of skin, first suture it in place at a few pointsand then continue to place sutures around the edges of the wound. Sutures arenot necessary for a small piece of skin.Haematoma formation under the graft is the most common reason for graftfailure. It can be prevented by applying a "bolster" dressing made of moist


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Orthopaedics and traum atoloav

Fig. 13.2 . Skin grafting. A skin-grafting knife (Humby type) (A); cutting skin (B);spreadingout the cut skin (C);making perforations in the graft (D).


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Soft-tissue injuries

cotton wool moulded in the shape of the graft and tied over the graft with su-tures. As an alternative, make several small perforations in the graft(Fig. 13.2D), or cut the graft into small pieces (postage-stamp grafts) and placethem a few millimetres from each other to leave space for bridging during there-epithelization process.

After-care Hold the graft in place with petrolatum gauze, unless you have already suturedit and applied a bolster dressing. Then apply additional layers of gauze andcotton wool, and finally a firm, even bandage. Leave the graft undisturbed for2-3 days unless infection or haematoma is suspected. Change the dressing dailyor every other day thereafter (a bolster dressing will no longer be needed by thisstage), but never leave the grafted area uninspected for more than 48 hours. Ifthe graft is raised, puncture i t to release any serum underneath. Otherwise inter-fere as little as possible. It may be possible to expose the graft to the air at thisearly stage if the area can be protected by splints or mosquito netting, but only ifthere is adequate nursing supervision. After 7 to 10 days, remove any sutures,wash the grafted area, and lubricate it with liquid paraffin (mineral oil) or petro-latum.The second week after grafting, instruct the patient in regular massage and ex-ercise of the grafted area, especially if it is located on the hand, the neck, or oneof the limbs. These exercises should be continued for at least 9 months. To pre-vent burn contractures, apply simple splints for flexure surfaces and keep thegrafts under tension using whatever means is available. For example, simpletongue depressors can serve as finger splints and plaster of Paris can be used forextremities.

Hand injuriesOpen injuries of the hand must receive prompt attention to prevent infectionand disability.

Assessment Take the patient's history and make a general assessment. Perform a local ex-amination: always check the circulation and sensory and motor functions in thepart distal to the wound. General or conduction anaesthesia may be required foran adequate examination of the wound. Use aseptic technique and handle thetissues gently. Identify nerve, vascular, and other soft-tissue injuries. Examinefor fractures by palpation.Determine whether the wound is clean or contaminated. A clean wound does nothave foreign matter or devitalized tissue. It is caused by sharp objects such asbroken glass, knives, or blades. A contaminated (dirty) wound contains more orless foreign matter and dead tissue, and should be considered susceptible to in-fection. Such wounds are caused by crushing or avulsion of tissue as in crushingor degloving injuries, lacerations and injuries from threshing machines.

Investigations Obtain radiographs of the underlying bones and joints.

Treatment Treatment consists of wound dkbridement and repair. Administer antibioticsand tetanus toxoid.

Equipment See tray for Minor operations, Annex 1, page 190, and include a tourniquet andsutures of 410,510, and 610 thread.


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Ortho~ aedics nd traumatoloav

Technique Use general or local anaesthesia as indicated by the extent of injury. Local anaes-thesia consists of infiltration with 1% lidocaine without epinephrine. Ring-block anaesthesia is convenient for finger injuries. Clean the wound thoroughlywith toilet soap and water, and then with 1% cetrimide or other antiseptic. Drythe wound and stop any oozing of blood by compression with sterile gauze. Foradequate exposure, extend the wound in line with the creases of the digit andpalm (Fig. 13.3A,B). Remove all remaining debris, foreign material includinggrass and grease, and detached or dead tissue. D o no t excise any s ki n unless i tis dead.Do not attempt to repair flexor tendons; refer the patient instead. Extensor ten-dons (Fig. 13.3C) may be repaired, unless there is gross contamination. Trim thefrayed, cut ends of the tendon minimally, and suture the two ends together with410 thread using the figure-of-eight technique (Fig. 13.3D-I). Once the twoknots have been tied they become buried in the anastomotic line (Fig. 13.3J,K).As a rule, nerve repair is an elective procedure requiring referral. However, if thecut ends of a digital nerve can be easily apposed, approximate them by a single510 or 610 thread stitch (Fig. 13.3L-0).

Woundcoverage Ensure meticulous haemostasis. Close a clean wound without tension by directinterrupted sutures. Always insert a corrugated or glove drain (Fig. 13.4A). Thewound may require coverage by a split-skin graft, especially if there has beenextensive skin loss.When there has been a degloving injury with amputation of the finger, the skinfrom the amputated part can be used (provided that it is not crushed and notobviously necrotic) as a temporary cover for the stump once it has been trimmed(Fig. 13.4B-D). If the wound is grossly contaminated or if there is exposure ofdeeper structures such as flexor tendons or the neurovascular bundle, delayclosure of the wound for a few days (delayed primary suture).When there is skin loss of less than 1 cm2, the wound is best left to granulatespontaneously, to produce a small acceptable scar. Skin loss of more than 1 cm2at the finger ti p or pulp is best covered with a split-skin graft, which will give asatisfactory cosmetic appearance, with partial sensation (Fig. 13.4E-G).An amputated fingertip can simply be stitched back to its bed, but not if the lineof amputation is proximal to the distal phalanx.

Dressing Cover the injured hand or finger with several layers of sterile, dry gauze(Fig. 13.5A-D). Apply a compression dressing and a light plaster slab to holdthe hand and wrist in about 20' of dorsiflexion, and the metacarpophalangealand interphalangeal joints in position of function. Leave the fingertips and nailsexposed (Fig. 13.5E-G).

After-care For the first 3-4 days elevate the limb, either by attachment to an overheadbeam if the patient is in bed (Fig. 13.5H) or by use of a triangular sling(Fig. 13.51), to reduce post-traumatic oedema; also encourage active exercisesand continue antibiotic treatment. Inspect the wound, hand, and fingers 72hours after the operation. Clean the wound, remove the drainage tube, and dressand splint the area. Refer the patient if indicated.

Complications Possible complications include infection, stiffness, and pain, or loss of sensation(in cases of nerve injury). Contracture is a possible late complication.


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Fig. 13.3. Repair of extensor tendon and digital nerve of the hand. Normal handshowing skin creases (A); extension of the wound (B); cut extensor tendon (C); trimmingthe cut end of tendon (D);repairing the tendon using figure-of-eight technique (E-K); cutdigital newe (L); apposingcut ends of the nerve with a single stitch (M-0).


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Fig. 13.4. Wound coverage for hand injuries. Closing a clean wound with interruptedsutures and inserting a drain (A); degloving injury with amputation of finger (B);trimming of the amputation stump and coverage with a split-skin graft (C, D); njury withskin loss from pulp of finger (E);applying split-skin graft (F ,G).

Subungual Subungual haernatoma causes severe pain due to the collection of blood deephaernatorna under the nail. The blood is liable to become infected. To relieve pain, sedate thepatient and allow the blood to escape through one or two small holes made inthe overlying nail with the red-hot tip of a 5-cm safety pin. The procedure ispainless.


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Soft-tissue injuries

Fig. 13.5. Dressing and elevation of hand injuries. Applying several layers of sterile, dry

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