External immobilization of the extremities is one of the oldest
forms of fracture treatment. References to plaster use and immobilization
techniques are scattered throughout historical records. The use
of plaster of paris (plaster) in fracture management dates back
to the eighteenth-century Turkish Empire. Plaster bandages became
commercially available in 1931. Despite the development of plastic
casting products, the plaster bandage persists as the most economical
and versatile material for immobilization techniques.1
Immobilization of an injured extremity begins at the scene of
the accident. According to Advanced Trauma Life Support guidelines,
the injured extremity must be aligned and immobilized after the
appropriate management of life-threatening problems.2 Prehospital
immobilization of fractures is invaluable for pain control, prevention
of soft tissue injury, and management of edema. External immobilization
with splinting or casting is often the definitive management of
injured extremities in the Emergency Department. Knowledge of and expertise
in this therapeutic procedure is essential for any Emergency Physician.
Splints are commonly used for the immobilization of upper and
lower extremity injuries. A splint is a hard bandage that is not
circumferential and prevents movement of the injured extremity. Splinting
may be the definitive management of certain injuries. Splints have
the distinct advantage of being quick and easy to apply. They are
designed to accommodate postinjury swelling. The major disadvantage
of splints is that they provide slightly less rigid immobilization
Casts, which are generally circumferential, are better suited
for the definitive treatment of fractures and ligamentous injuries.
Casts provide superb immobilization and allow for the maintenance
of a reduced fracture. The rigidity of a cast limits the amount
of swelling and soft tissue edema and is therefore associated with
an increased risk of developing a compartment syndrome. Casts should be used with caution in the
management of acute fractures. They are often split (bivalved) to
allow swelling and prevent the development of a compartment syndrome
before the patient is discharged from the Emergency Department.
Casts and splints rely on the principle of a three-point mold
to maintain fracture reduction (Figure 76-1). When
applying a cast or splint, the application of directed force to
the underlying bones should be uppermost in one’s mind. To
obtain a three-point mold, place one point of contact over the convex
side of the fracture site. The other two points of force are aimed
in an opposite direction, proximal and distal to the fracture on
the concave side. This is the classic teaching of Sir John Charnley,
who noted that “a curved plaster is necessary in order
to make a straight limb.”3 A skin-tight cast that
closely follows the contours of the extremity will not maintain
the fracture in alignment, as it does not apply appropriate pressure
to the underlying bones.
Three points of force are acting on the injured ...
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