FRACTURE TYPES , POP TECHNIQUES AND COMPLICATIONS

Moderators :Dr. Prabhu .B Professor

Dr. Ramesh.R Presented By Professor Dr. Venkatesh Ghantasala Post graduate

Department Of Orthopaedics J.J.M. Medical College- Davangere

TOPICS

1. Fracture Types And Classification.

2. Pop Techniques

3. Complications Associated With Pop Techniques

FRACTURE TYPES AND CLASSIFICATIONS

1.1 PURPOSE OF FRACTURE CLASSIFICATION SYSTEMS : • To characterize fractures as far as certain general and specific features.

• To guide treatment.

• To predict outcomes or prognosis

• To speak a common language with other surgeons globally.

1.2 HISTORY OF FRACTURE CLASSIFICATION :

•Fracture classifications have existed much longer than have radiographs

•Edmund Smith Papyrus , though did not make a clear distinction between comminuted and non-comminuted fractures , clearly classified fractures as open or closed , and provided guidelines for treatment based on that classification.

•In the 18th and 19th centuries , still prior to the discovery of radiographs , there were in existence fracture classification systems that were based on the clinical appearance of the limb alone

•Nearly all fracture classification systems in use today are based upon on the analysis of plain radiographs of the fractured bone.

1.3 TYPES OF FRACTURE CLASSIFICATION SYSTEMS :

Classification systems used to characterize fractures can be categorized into three broad categories :

1. Those that are fracture specific , which were generated for the classification of a single fracture in a single location in the skeleton.

Eg: Garden classification of femoral neck fractures Schatzker classification of proximal tibia fractures

2. Those that are generic or universal fracture classification systems , which apply a single, consistent methodology to the classification of fractures in all parts of the human skeleton.

Eg : The AO/OTA (Orthopaedic Trauma Association) fracture classification of long bones is essentially the only generic or universal system in wide usage today.

3. Those based on soft tissue injury associated with the fractures.

Eg : Gustilo and Anderson classification for open fractures Oestern and Tscherne classification for closed fracture

GUSTILO AND ANDERSON CLASSIFICATION SYSTEM OF OPEN FRACTURES

OESTERN AND TSCHERNE CLASSIFICATION SYSTEM OF CLOSED FRACTURES•Closed fracture grade 0 (Fr. C 0): There is no or minor soft-tissue injury with a simple fracture from indirect trauma. A typical example is the spiral fracture of the tibia in a skiing injury.

•Closed fracture grade I (Fr. C 1): There is superficial abrasion or skin contusion, simple or medium severe fracture types. A typical injury is the pronation-external rotation fracture dislocation of the ankle joint: The soft-tissue damage occurs through fragment pressure at the medial malleolus.

•Closed fracture grade II (Fr. C 2): There are deep contaminated abrasions and localized skin or muscle contusions resulting from direct trauma. The imminent compartment syndrome also belongs to this group. The injury results in transverse or complex fracture patterns. A typical example is the segmental fracture of the tibia from a direct blow by a car fender.

Closed fracture grade III (Fr. C 3): There is extensive skin contusion, destruction of muscle or subcutaneous tissue avulsion (closed degloving). Manifest compartment syndrome and vascular injuries are included. The fracture types are complex.

1.4 FRACTURE TYPES :

Definition :

A fracture is defined as a break in the continuity of the bone.

Based On Mechanism:

1.Traumatic Fracture – Fracture sustained due to trauma. Eg .- Fractures caused by a fall , RTA.

2.Pathologic Fracture – A fracture through a bone which has been made weak by some underlying bone disease. Eg .- A fracture through a bone weakened by metastasis or Osteoporosis.

3. Periprosthetic Fracture – A fracture at the point of mechanical weakness at the end of an implant.

PATHOLOGICAL # PERI PROSTHETIC #

Based On Soft Tissue Involvement:

1. Simple/Closed fracture: Those in which the overlying skin and soft-tissues are intact.

2. Open fracture/Compound fracture: Involve wounds that communicate with the fracture, or where fracture hematoma is exposed, and may thus expose bone to contamination. Open injuries carry a higher risk of infection.

Based On Displacement:

1.Undisplaced : None or minimal displacement of fracture fragments.

2.Displaced : Depending on fracturing force , muscle pull on the fracturing fragments and the gravity, the displacement may be

Translation AngulationRotatation

While describing the displacements of fracture , conventionally , it is the displacement of the distal fragment in relation to the proximal fragment which is mentioned.

Based On Fracture Pattern: 1.Linear fracture : A fracture that is parallel to the bone's long axis.

2.Transverse fracture: A fracture line is at right angle to the bone's long axis. Caused by tapping or bending force.

3.Oblique fracture: A fracture that is diagonal to a bone's long axis. Caused by bending force in addition to force along long axis of the bone.

4.Spiral fracture: A fracture where at least one part of the bone has been twisted. Fracture line runs spirally in more than one plane. Caused by twisting force.

5.Compression fracture/Wedge fracture: usually occurs in the vertebrae , for example when the front portion of a vertebra in the spine collapses due to osteoporosis where vertebrae become brittle and susceptible to fracture, with or without trauma.

6.Impacted fracture: A fracture caused when bone fragments are driven into each other.

7.Avulsion fracture: A fracture where a fragment of bone is separated from the main mass.

8.Segmental fracture : In this there are two fractures in one bone , but at different levels

Based On Fragments :

1.Incomplete fracture: A fracture in which the bone fragments are still partially joined. In such cases, there is a crack in the osseous tissue that does not completely traverse the width of the bone

2. Complete fracture: A fracture in which bone fragments separate completely.

3. Comminuted fracture: A fracture in which the bone has broken into several pieces.

PEDIATRIC FRACTURES :

•The anatomy and biomechanics of pediatric bone differ from that of adult bone, leading to unique pediatric fracture patterns , healing mechanisms , and management.

• In comparison to adult bone , pediatric bone is significantly less dense , more porous and penetrated through out by capillary channels . Pediatric bone has a lower modulus of elasticity, lower bending strength , and lower mineral content .

•The low bending strength induces more strain in pediatric bone than for the same stress on adult bone and the low modulus of elasticity allows for greater energy absorption before failure .

•The increased porosity of pediatric bone prevents propagation of fractures , there by decreasing the incidence of comminuted fractures.

•The pediatric periosteum is extremely strong and thick, functioning in reduction and maintenance of fracture alignment and healing.

Pediatric Bone

Lower Modulus Of

Elasticity

Highly Porous

Lower Bending

Strengt

h

Greater Energy

Absorption

Induces More Stess

Prevents Propagatio

n Of #

Pediatric Fracture Patterns :

1. Plastic Deformation or Bowing fracture 2. Torus OR Buckle fracture

3. Greenstick fracture

4. Complete fracture

5. Physeal fractures

•A force produces microscopic failure on the tensile/convex side of bone which does not propagate to the concave side. •The bone is angulated beyond its elastic limit, but the energy is insufficient to produce a fracture

•No fracture line is visible radiographically.

•Most commonly seen in the ulna, occasionally in the fibula.•Bend in the ulna of < 20° in a 4 year old child should correct with growth.

1. Plastic Deformation or Bowing fracture :

2. Torus OR Buckle fracture

•Incomplete fractures of the shaft of a long bone that is characterised by bulging of the cortex.

•Compression failure of bone that usually occurs at the junction of the metaphysis and the diaphysis.

•They result from trabecular compression from an axial loading force along long axis of the bone.

•Distinct fracture lines are not seen. subtle deformity o r buckle or a bump of the cortex may be evident.

•Latin word tori which means protuberance

•Heals in 3-4 weeks with simple immobilization

3. Greenstick fracture

•Bone is bent and the tensile/convex side of the bone fails.

•Fracture line does not propagate to the concave side of the bone, therefore showing evidence of plastic deformation.

•If the bone undergoes plastic deformation, it is necessary to break the bone on the concave side to restore normal alignment, as the plastic deformation recoils the bone back to the deformed position.

• The name is by analogy with green (i.e., fresh) wood which similarly breaks on the outside when bent.

5. Physeal fractures

•Fractures to the growth plate can be caused by i) crushing, ii) vascular compromise of the physis or iii) bone growth bridging from the metaphysic to the bony portion of the epiphysis.

•Damage to growth plate may result in progressive angular deformity, limb-length discrepancy or joint incongruity.

•The distal radial physis is the most frequently injured physis.

•Most physeal injuries heal within 3 weeks. This rapid healing provides a limited window for reduction of deformity.

• Physeal injuries are classified by the Salter-Harris (SH) classification system, based on the radiographic appearance of the fracture.

Corner Fracture Or Bucket-Handle Fracture :

•A corner fracture or bucket-handle fracture is fragmentation of the distal end of one or both femurs , with the loose piece appearing at the bone margins as an osseous density paralleling the metaphysis. •The term bucket-handle fracture is used where the loose bone is rather wide at the distal end , making it end in a crescent shape.

•These types of fractures are characteristic of child abuse related injuries

Fractures With Eponyms :

Few fractures have eponyms. Few are named after the person who demonstrated first and few are named according to the mode of injury.

1. Arm

•Holstein-Lewis Fracture – A fracture of the distal third of the humerus resulting in entrapment of the radial nerve.

2. Forearm

•ULNAR FRACTURES1.Monteggia Fracture dislocation – A fracture of the proximal third of the ulna with the dislocation of the head of the radius. It may be of extension type or flexion type depending on the angulation of ulna.

2. Hume Fracture – A fracture of the olecranon with an associated anterior dislocation of the radial head

3.Night Stick Fracture –

Isolated fracture of the shaft of ulna sustained while trying to ward off a stick blow.

•RADIUS FRACTURES :

1. Essex-Lopresti Fracture – A fracture of the radial head with concomitant dislocation of the distal radio-ulnar joint with disruption of the interosseous membrane.

2. Galeazzi Fracture:

A fracture of the lower third of radius with dislocation or subluxation of the distal radio-ulnar joint.

3. Colles' Fracture :

Fracture of the distal end of the radius at its cortico-cancellous junction with various types of displacements of distal fragment , accordingly it may be -

Impaction of fragmentsDorsal displacementDorsal tiltLateral displacementLateral tiltSupination

4. Smith's Fracture :

Fracture of the distal end of radius at its cortico –cancellous junction with dorsal fragment being displaced ventrally or tilts ventrally.

5. Barton's Fracture :

An intra-articular fracture of the distal radius with dislocation of the radiocarpal joint. Depending on the extension of fracture line to either of the anterior or posterior cortices. It may be a. Volar barton(anterior marginal type) b. Dorsal barton (posterior marginal type)

Dorsal Barton

Volar Barton

6. Chauffeur Fracture :

An intra articular oblique fracture of styloid process of radius.

7. Side-Swipe Fracture OR Baby Car Fracture :

It is a combination of fractures of distal end oh humerus with the fractures of proximal ends of radius and/or ulna. Sustained when one’s elbow projecting out of a car, is side swept by another vehicle.

3. HAND

1. Rolando Fracture - A comminuted intra articular fracture through the base of the first metacarpal bone.

2. Bennett's Fracture –

An oblique intra-articular fracture of the base of the first metacarpal bone with subluxation or dislocation of the metacarpal. Fracture line extends into the carpo-metacarpal (CMC) joint.

3. Boxer's Fracture -

A fracture at the neck of a metacarpal. Commonly 5th metacarpal sustained when a closed fist hits against a hard object.

3. Mallet Finger Or Base Ball Finger – A finger flexed at the DIP joint due to avulsion or rupture of extensor tendon at the base of distal phalynx resulting from sudden passive flexion of DIP joint.

4. TIBIA :

1. Pilon Fracture - Comminuted intra articular fracture of distal end of tibia.

2. Bumper Fracture -

A fracture of the lateral tibial plateau caused by a forced valgus applied to the knee.

3. Segond Fracture - An avulsion fracture of the lateral tibial condyle.

4. Gosselin Fracture -

A fractures of the tibial plafond into anterior and posterior fragments

5. Toddler's Fracture - An undisplaced and spiral fracture of the distal third to distal half of the tibia seen in toddler age group of 9 months to 3 years.

5. Fibula

1.Maisonneuve Fracture - A spiral fracture of the proximal third of the fibula associated with a tear of the distal tibiofibular syndesmosis and the interosseous membrane.

3. Bosworth Fracture-Dislocation -

A fracture with an associated fixed posterior dislocation of the proximal fibular fragment which becomes trapped behind the posterior tibial tubercle. The injury is caused by severe external rotation of the ankle.

2. Le Fort Fracture Of Ankle -

A vertical fracture of the antero-medial part of the distal fibula with avulsion of the anterior tibiofibular ligament

6.Combined Tibia And Fibula :

1. Pott’s Fracture- Bimalleolar ankle farcture - involving the

lateral malleolus and the medial malleolus.

2. Cotton’s Fracture- Trimalleolar ankle fracture - involving

the lateral malleolus, medial malleolus and the distal posterior aspect of the tibia.

7.Foot

1. Lisfranc Fracture -

In which one or all of the metatarsals are displaced from the tarsus. The articulation between fore foot and mid foot is referred to as lisfranc joint.

2. Jones Fracture -

A fracture of the base of the fifth metatarsal bone.

3. March Fracture -

A fracture of the distal third of one of the metatarsals occurring because of recurrent stress.

4. Aviator’s Fracture – Fracture of the neck of the talus.

5..Chopart Fracture-Dislocation –

A fracture dislocation of the mid tarsal joints i.e talo-navicular and calcaneo-cuboidal joints. The articulation between hind foot and mid foot is commonly referred as chopart joint and hence the fracture name.

8.Pelvis :

1.Duverney Fracture - An isolated pelvic fracture involving only the iliac wing.

2.Straddle Fracture- Bilateral superior and inferior pubic rami fractures

3.Malgaigne’s Fracture- A type of pelvis fracture in which there is combination of fractures, pubic rami anteriorly and sacro-iliac joint or ilium posteriorly on the same side.

9.Hip Dashboard Fracture –

Fracture of the posterior lip of acetabulum often associated with posterior dislocation of hip.

10.Spine

1. Jefferson Fracture :

Fracture of the anterio and posterior arches of the C1 vertebra

2. Hangman's Fracture-

Fracture of both pedicles or pars interarticularis of the C2 vertebra with or without subluxation of C2 over C3 sustained in hanging.

3. Flexion Teardrop Fracture –

Posterior ligament disruption and anterior compression fracture of the verterbral body which results from a severe flexion injury.

4. Clay-Shoveler Fracture –

Fracture through the spinous process of a vertebra occurring at any of the lower cervical or upper thoracic vertebrae.

5. Burst Fracture -

Comminuted farcture of the vertebral body in which atleast two columns are broken from a high-energy axial load.

7. Chance Fracture –

Compression injury to the anterior portion of a vertebral body with concomitant distraction injury to posterior elements.

It is a three column injury with a horizontal orientation of the fracture. Also called seat-belt fracture. The classic mechanism of this injury is a lap-belt injury.If you don't have an addtional shoulder belt, the body will fold over

9.Translational Injuries -

They are associated with shearing forces that disrupt all three columns.

The shearing forces are most often directed posteriorly to anteriorly but may also be directed anteriorly to posteriorly. Since the ligament of the spinal canal is affected, these injuries are always unstable and are associated with a very high incidence of neurologic deficit.

2. POP(PLASTER) TECHNIQUES PLASTER OF PARIS

HISTORY: •Hippocrates in 350 B.C. used bandages stiffened by waxes and resins.

•The ancient Egyptians used wooden splints made of bark wrapped in linen.

•Ancient hindus treated fractures with bamboo splints

•In 13th century POP was used for walls in England.

•Cheselden , an English surgeon in the 18th century used bandages soaked in egg white and flour to form a cast.

•NILOLAI IVANOVICH PIRIGOV (1810-1881) Plaster of paris dressings were first employed in the treatment of mass casualities in the 1850s during Crimean war.

•Koyle & kluge from berlin in 1828 used box-casts.

•The name POP was derived from an accident to a house built on a deposit of Gypsum, near Paris. •The house burnt down. When rain fell on baked mud of the floors it was noted that foot prints in mud set rock hard.

CHEMICAL FORMULA : 

2CaSO4·½H2O +  3H2O ==> 2CaSO4·2H2O + heat

Hemi hydrated calcium sulphate Hydrated calcium sulphate (POP) (GYPSUM)

HOW IS POP

PREPARED ??

POP is made from

crystalline

gypsum by

heating in

controlled

conditions (120o

– 160o C) in a

steam autoclav

e.

The powder

is treated

in a solvent

with various

additives.

The suspensi

on is coated into a

special interwoven cloth called LENO.

The bandages

are cut and rolled

in a moisture

free containers

ORTHOPAEDIC USES OF POP : • To support fractured bones

•To stabilize joints in ligamentous injury

•To immobilize joints and limbs after surgery.

•To correct deformity as in CTEV

•To make a negative mould of a part of body for construction of an orthosis or prosthesis.

USED IN 4 FORMS MAINLY : • Slab

• Cast

• Spica

• Functional Cast Brace.

RULES OF APPLICATION OF POP : •Choose the correct size of the roll

• A joint above and a joint below the fracture/injury should be included.

•Plaster should not be too tight or too loose.

•Padding should be from distal to proximal with 50% overlap, with extra padding over bony prominences like malleoli, patella, olecranon and fibular head

•Moulding should be done with palm not with fingers to avoid indentations.

•A cast should never be applied carelessly with the thought in mind that it can be changed next month if it turns out to be imperfect one.

• One should apply a plaster with the idea that it might be made to last for the whole period of treatment.

PADDING : •1-2 layers or more depending on the amount of swelling.

•Extra over elbows and heels.

•Be generous over bony prominences.

•Always pad between digits when splinting hands/ feet or when doing buddy strapping.

•Avoid wrinkles and lumps.

•Not to be applied tightly- danger of ischemia !!

•Just before completion of plaster application make sure that padding material(cotton ) is turned back and loose edges are secured with a turn or two of plaster bandage if cast is applied ; and with encircling gauze bandage in case of slab application.

STOCKINET :

•It protects skin and makes the bandge application looks nifty.

•To be applied on the skin before the padding is done.

•Always cut the stockinet longer than the splint to be applied.

•Available in 2,3,4,8,10,12 inches width.

Setting time : Time taken to change from powder form to crystalline form.

Drying time : Time taken to change from crystalline form to anhydrous form.

Average setting time : 3-9 minutes.

Average drying time : 24-72 hours.

FACTORS DECREASING SETTING TIME :

Hot water Salt Borax Resin

FACTORS INCREASING SETTING TIME :

Cold water Sugar

BASIC PLASTERING TECHNIQUE :

• Palstering is a form of craft.

• Skill not to be learned from books but by continuous practice.

• A good manipulative reduction can be spoiled due to a clumsy plaster application.

SLAB :•Slab is a temporary splint made up of half by POP and half by bandage roll.•Used in initial stages of fracture treatment, during first aid and to immobilize the limbs post operatively.

Steps in application of slab –•Slab is measured into required length

•For upper extremities use 8-10 layers and for lower extremities use 12-15 layers or upto 20 depending on size of the person

•Trimmed to the requirement of of the area of application

•Slab held carefully at both ends and immersed completely in tepid water.•Lift out and momentarily bunch up at an angle to expel excess water.

•Consolidate the layers of the slab to remove excess of air as retained air causes reduction of plaster strength.

•Slab is positioned and smoothened out with the hands so that the slab fits closely to the contours of the limb.

•Wet bandage is applied to avoid tightening from shrinkage after coming in contact with the slab.

Below Elbow Slab:Indications –•Wrist fractures•Metacarpal fractures •Colle’s fracture

Extends from a point about 5 cm below the top of the olecranon or 2 fingers breadth distal to elbow crease to the level just proximal to the knuckles in the dorsum of the hand and the distal crease in the palmar aspect.The forearm is held with the elbow in a 900 flexed and the wrist in the position of function of 250 dorsiflexion for wrist fractures. The fingers should be free to move fully at the metacarpo-phalangeal joints.Wrist in 40-45 degrees of dorsiflexion and MCP joints in 90 degrees and IP joints in full extension (cock-up position) for metatarsal fractures.

Above elbow slab in elbow flexion :Indications•Fracture both bones forearm•Supracondylar # humerus of extension type•Unstable proximal radius or ulnar #

Above elbow slab in elbow extension :Indications•Olecranon #•Supracondylar # humerus of flexion type.

Extends from the middle of the upper arm to the point just proximal to the knuckles in the dorsum of the hand.

patient's forearm is held in mid prone position with the elbow in 900 flexed position or full extension depending on the type of fracture.

U SLAB OR COAPTATION SLAB :

Indications :

For Proximal and shaft of humerus fractures.Applied to the medial and lateral aspects of the arm, encircling the elbow and overlapping the shoulder.Utilizes dependency traction and hydrostatic pressure to effect fracture reduction

Below knee slab

Indications:

•Ankle fractures and dislocations post reduction•Tarsal and Meta tarsal fractures.

Position :Proximal end – upto tibial tuberosity.Distal end – upto MTP joints of foot.Foot in neutral position.

Above Knee Slab

Indications

• Proximal and mid shaft Tibial fractures.•Supra condylar # of femur

Proximal end – as high in the groin as possibleDistal End – to mp joints of footKnee in 5 to 15 degrees flexionFoot in neutral position

CAST :•In this form of splinting POP roll completely encircles the limb.

•Casting is used as a definitive form of fracture management and also to correct deformity.

Steps in application of cast :

• After stockinet application and tidy , uniform padding select the appropriate width of POP roll to be applied (generally 4 inch or 6 inch)

•Dip the roll in tepid water completely.

•Secure the end of bandage to prevent it from getting lost.

•Hold the bandage lightly with the other hand without compression.

•Immerse at an angle of 45o

•Keep under the water until bubbles start rising.

•Remove the excess water by compressing in axial direction. Depending on the amount of padding , plaster casts are divided broadly into 3 types:

Badly padded plaster

Unpadded plaster

Padded plaster.

Badly padded plaster :

• Bohler advocated this plaster application.

• It is loose on the limbs and cannot fix fragments.

Unpadded plaster :

• Pop bandage directly applied to skin without intervention of any textile.

• Advocated by Bohler.

• Believed to enhance the fixation of fractures.

• For practical purposes, if stockinet is used the resulting plaster can still be regarded as an unpadded cast.

•The bandage is made to roll itself round the limb.

• The closeness of its application to the limb and actual adhesion to the skin is believed to enhance fixation of fragments.

•Bandage should never be pulled tight.

•Should be applied by laying the wet roll of plaster on the skin and pushing it round the curves of limb with flat of hand.

•The roll of plaster should not be lifted off the limb and pulled.

Padded plaster : • Advocated by Bologna school

•Layer of cotton wool is interposed between the skin and plaster.

•Cotton applied as an even layer of rolled wadding.

•The elastic pressure created by cotton enhances the fixation of limb by compensating for shrinkage of tissues.

•The care with which cotton is applied is essential for success.

•The cotton should not obscure the shape of the limb by being put in careless and ugly lumps.

• Bandage is pressed and pushed round the limb by the pressure of the thenar eminence under a strong pushing force directed in length of surgeons forearm.

• Pressure is applied at the middle of the bandage so that no excess of pressure can fall on either edge.

•Each turn is applied slowly and is settled carefully in position.

• At tapering parts of the limb the turns are made to lie evenly by small tucks which are made with quick movement of index finger of left hand.

• The hall mark of good plaster is that it should be of even thickness from end to end

Two person team

. Materials (prepared before the procedure)

. Positioning of the limb

Application of the padding

Handling of plaster bandages

Application of plaster bandages

Final Manipulation Is Done And The Reduction Held, With Appropriate Molding, Until The Plaster Hardens.

During the evaporation period, the casted limb should remain exposed and not fully covered by blankets.

TRIPLE SEQUENCE IN PLASTER APPLICATION :

Phase 1 : Examination And Rehearsal

Phase 2 : Plastering

Phase 3 : Reduction And Holding

Phase 1 : Examination And Rehearsal

• Examination of the displacement and assessment of the forces required to reduce and hold the reduction.

• Need to assess effect of gravity on the displacement.

• Range of excursion from the position of greatest deformity to the position of apparent reduction.

Phase 2 : Plastering • Limb held by assistant in position of approximate reduction. • Surgeon himself should apply the bandage.

• Quick application is more important than holding precise reduction.

• Plaster should still be completely soft after completion to allow final touches

Phase 3 : Reduction And Holding

•After applying sufficient plaster , surgeon prepares to apply the rehearsed movement of reduction.

•Should be able to clearly recognize sensation of reduction.

•After applying rehearsed reduction, surgeon holds on, without further movement to allow the cast to set.

•In the last few minutes, he should obliterate any abrupt impression that might invite pressure sores.

•NOT TO FORGET CHECK XRAY should be done after application of each cast to confirm the acceptability of reduction.

FUNCTIONAL CAST BRACE : •Advocated by August Sarmiento

•It is a non surgical method of fracture treatment in which hydraulic action of the muscles is used to hold the fragments in alignment using a brace. •A well fitting plaster cast is applied and the patient starts using the extremity i.e. allowed to walk on the cast. Muscle action and the intermittent axial compression stimulates bony union.

•Not suitable for fresh fractures.

•Suitable for fractures of tibia and femur and selected stable upper extremity fractures.

• Care should be taken to correct any angular or rotational deformity upon the position of the fragments before the brace is applied.

• A period of immobilization in a conventional cast is required

Pre- requisites :

• Minor movements at the fracture site should be painless.• Any deformity should disappear once the deforming force is removed• Shortening should not exceed 6mm for tibia and 1.25 cm for femur.• Reasonable resistance to telescoping.

SPICA : A cast of layers overlapping in a V pattern, covering two body

parts of greatly different in size, as the hip and waist, thumb

and wrist, etc.

Eg : Hip spica cast Thumb spica cast

Advantages Of POP :

•Cost effective

•Non allergic

•Easily moulded to different forms.

Disadvantages of POP :

•Radio-opaque , may occlude # lines

•Heavy

•Easily breaks when comes in contact with water.

AFTER CARE OF POP :

• Keep the plaster cast dry.

• Mobilize all the joints which are not incorporated in the plaster to their full range of motion once it becomes dry.

• Come immediately if any of the following symptoms developExcessive painExcessive swellingBluish or white discoloration of fingers or toes •Notice any cracks in the plaster.

•Graduated weight bearing for lower limb #

•Physiotherapy of muscles within the plaster and joints outside the plaster is necessary to ensure early rehabilation.

WELLINGTON BOOT EFFECT :

In below knee plasters it is important that bandage should be

pulled very tight in the proximal part because, unless the wool

and the soft muscles are both powerfully compressed it will be

found that plaster when completed will be as loose as the

wellington boot.

3. COMPLICATIONS OF POP Due to tight cast •Pain

•Pressure sores – The patient’s complaints of a painful cast should never be ignored, and the cast should be changed promptly. Often, this may reveal an area of early skin pressure or irritation that could progress to full-thickness skin loss.Compartment syndrome and the resulting sequelae Volkmann's Ischaemic contracture.

• Peripheral nerve injuries

Due to improper applications :

• Joint stiffness and malposition of limb.

• Plaster blisters and sores.

Due to plaster allergy :

• Allergic contact dermatitis –

The skin symptoms of irritation were all mild and temporary.

Quaternary ammonium compound BENZALKONIUM CHLORIDE is the allergen responsible for plaster of Paris-induced allergic contact dermatitis

Disuse Atrophy and Muscle Weakness –

• Muscles that do not function when under cover of plaster will atrophy

• Not only can this result in cast loosening, but there may also be functional loss.

• Motion and isometric exercises should be encouraged.

• Prolonged non–weight-bearing treatment in a cast can also result in disuse osteopenia, which can complicate recovery. • Typically, radiographic features include loss of trabecular pattern, a speckled or mottled appearance of the periarticular surface, and a generalized “WASHED-OUT” appearance

PLASTER DISEASE : When a limb is put into POP and the joints immobilized for a long period , joint stiffness, muscle wasting and osteoporosis are unavoidable.

This syndrome can be reduced to a minimum by the early use of functional braces, isometric exercise and early weight-bearing. These in turn promote a rapid retrieval of function.

FRACTURE DISEASE :

• A constellation of symptoms and physical changes has been called “fracture disease.”

• Prolonged immobilization, especially in a nonfunctional cast, can lead to a vicious cycle of pain, swelling, and unresolved edema.

• Edema fluid is a proteinaceous exudate that will congeal and gets converted to a gelatinous material and deposited as a scar tissue around joints and tendons causing joint stiffness, contracture and tendon adhesions. • Muscle atrophy, brawny skin /induration, and osteoporosis follow

• Reflex sympathetic dystrophy may sometimes occur and further complicate the picture

CAST SYNDROME : • Cast syndrome is a rare complication that is seen related to body jacket, shoulder spica, and hip spica

• The syndrome occurs due to arteriomesenteric duodenal obstruction, and it is a result of excessive abdomen and chest coverage.

• Symptoms are severe, and if left untreated, can be potentially lethal.

• Compression of the third part of the duodenum between the lumbar spine and the aorta posteriorly and the mesentry and vessels anteriorly.

• This syndrome is precipitated by recumbency and increased lumbar lordosis. • Avoiding constrictive body casts that increase lumbar lordosis prevents cast syndrome.

• Nausea, epigastric fullness, and regurgitation should be carefully evaluated.

SPECIAL BANDAGES :

POP bandages prepared on elastic gauze instead of cotton cloth. These bandages can stretch when wet to suit the shape of limb.

E.g. ORTHOFLEX - Orthoflex Elastic Plaster Bandages are ideal for difficult casting procedures such as post-amputation, as they conform well to body contours and bony prominences.Sets fast in 5 - 8 Minutes.

FIBRE GALSS CAST :

• A fiberglass cast is a lighter, synthetic alternative to the more traditional plaster version. • It is created by padding the extremity with cotton or waterproof padding material, followed by wrapping several layers of knitted fiberglass bandages impregnated with a water-soluble, quick-setting resin

Advantages :•Short setting time•Immediate weight bearing•Strong but weighs light• Radiolucent•Water resistance•Wicks moisture better

Disadvantages :

• High cost• Can’t be applied over wet wounds or immediately after trauma• Difficult to remove• Leaves sharp edges• Less mouldable

POLYMER RESIN CASTS:

Bandages of cotton, fibre glass or polypropylene impregnated with resin which hardens on contact with water. Rapid setting and water resistance combined with porosity and radiolucency.

THERMOPLASTICS :

Plastics which are pliable when heated and hardened when cooled. This property helps to modify casts or splints. • Low temperature thermoplastic splints can be softened in hot water and placed directly on the skin and are most appropriate for upper limb fractures or injuries. • High temperature thermoplastic splints are made from a cast and require higher temperatures and a longer curing time to harden. These splints are better suited for lower limb or back injuries that generally require a longer healing period

CORTEX EXOSKELETON….

• Latest potential application of advanced materials manipulation.

•Cortex Exoskeleton concept addresses those factors using advanced 3D printing techniques.

•An X-ray of the fracture is combined with a 3D scan of the limb, and then a custom sleeve is printed, complete with extra“membrane” structuring around the exact point of the injury.

IDEAL CAST :

•Suitable for direct application•Easy to mould or remould•Nontoxic for patient•Unaffected by water•Transparent to x-rays•Quick setting• Able to transmits air, water, odour and pus•Strong but light in weight•Non-inflammable•Non messy application and removal•Long shelf life•cheap