Closed plaster treatment of severe compound injuries – A report and revisit


Published on

A crushed injury of limb was treated with closed plaster method and elaborating the treatment protocol and follow-up. We should look behind the old treatment method again.

Published in: Health & Medicine
  • Be the first to comment

  • Be the first to like this

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Closed plaster treatment of severe compound injuries – A report and revisit

  1. 1.                                                                                                   C                                      losed pla inj        aster treatm uries - A ment of s report an      severe com nd revisit mpound
  2. 2. Case Report Closed plaster treatment of severe compound injuries e A report and revisit Pankaj Kumar* Consultant Orthopaedic and Spine Surgeon, Apollo Reach Hospital, Karimnagar, Andhra Pradesh 505001, India a r t i c l e i n f o Article history: Received 26 October 2012 Accepted 17 May 2013 Available online 10 June 2013 Keywords: Crush injuries Treatment POP a b s t r a c t A crushed injury of limb was treated with closed plaster method and elaborating the treatment protocol and follow-up. We should look behind the old treatment method again. Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved. 1. Introduction The closed method has been known for nearly a century, and the principles upon which it is based were known to Hippo- crates, who stated that rest and immobilisation are of capital importance in the treatment of wounds. Billroth1 used plaster of Paris fixation with a window over the wound and a no dressing. Ollier2 was the first to enclose the wound completely in plaster. He treated 60 cases by his occlusive method in the FrancoePrussian War, and described his results in 1872. In 1881, Morisons3 of Newcastle-on-Tyne strongly advocated large, firm dressings for wounds, to be undisturbed for three to four weeks. The closed treatment of wounds is based on sound prin- ciples. The technique is exact and attention must be paid to every detail if success is to be assured. 2. Principles upon which the method is based A. Excision and surgical toilet: Primarily the object of early excision of dead and devitalised skin, muscle, fascia etc, is to get beyond the depth of penetration of bacteria and in addition to remove dead tissue which would form an ideal nidus for organisal growth. Dead muscle especially is an ideal culture medium for the gas gangrene organisms. The excision, thus, must be thorough and wide. The necessity for removal of accessible foreign bodies, bits of cloth, etc., is obvious. Generally speaking, wounds seen up to 8 h of infliction may be excised. When obvious infection is already present, provision for drainage only should be made, and no formal excision should be carried out. B. Drainage: All parts of the wound must be left with free access to the surface for the evacuation of discharges, and * Tel.: þ91 (0) 9618123678 (mobile). E-mail addresses:, Available online at journal homepage: a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 1 3 4 e1 3 6 0976-0016/$ e see front matter Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved.
  3. 3. there must be complete freedom from tension in the wound. Wide openings, with “saucerisation”, and efficient packing with Vaseline gauze, so as to form a conical pack, fill these requirements. Tubes and sutures should not be used. C. Immobilisation: This is essential for healing of fractures, for repair of injured soft tissues, and for prevention of pain. Plaster of Paris, applied, including the joint above and below the wound is the best form of fixation. No window is cut over the wound, as “window oede- ma”occurs, and healing is delayed. Trueta and Barnes4 have proved experimentally that bacteria and certain toxins (including tetanus toxin) are absorbed from wounds into the blood-stream via the lymphatics only. They are not absorbed when the lymphatics are obstructed or when the limb is completely immobilised in plaster. They have also shown that flow of lymph from a limb is increased by movement, heat, massage and oedema. All efforts in wound treatment, there- fore, must be directed to the reduction of lymph flow from the limb. Complete immobilisation by means of a well fitting plaster and prevention of oedema by a vaseline pack. No window in the plaster, adequate local drainage, and elevation of the limb, effectively. 3. Contraindication The method is not to be used: A. When a vascular lesion is present or when the circulation of the limb is in doubt. Gas gangrene organisms flourish in dead or poorly nourished muscles. These cases must he observed or a few days before applying plaster. B. When there is any suspicion of true gas gangrene. If there is the slightest doubt about the significance of gas bubbles or any anxiety about the state of nutrition of the limb, it is better not to use the closed plaster. C. When there is so much contusion and crushing of the limb that all devitalised tissue cannot possibly be excised and there is risk of extensive necrosis subsequently, D. In cases of severe multiple injuries, e.g. wounds of hu- merus and chest, or of femur and abdomen, where a plaster would interfere with the wounds on the trunk. E. When extensive spreading cellulitis, e.g. Streptococcal or anaerobic (B.welchii), cellulitis is present, plaster applica- tion should be deferred until this has settled down. 4. Case report A 7 years boy reported to the emergency department with his- tory of playing near parking, when driver started the car his one leg trapped inside the wheel of car and in hurry somebody tried to pull his leg from the wheel of car. While pulling he got this severe injuries. His leg and foot were crushed. He reported to emergency department within 3 h of injuries with active bleeding from wound and with hypovolemic shock. When we examined the limb there was almost complete degloved lower two third right leg with visible anterior two third of tibia and fibula and anterior part of all bone of foot, visible all tendon including all around the ankle joints and tendon anterior to foot was lost, with novisible pulsationbut sole offoot was intact and there was active bleeding from muscles. We corrected the shock, and X-ray showed there were multiple fractures of metatarsal bone and without fracture of tibia and fibula. We planned for wound debridement and K-wire fixation of bone and coverage of bone by the help of plastic surgeon. According toplasticsurgeon itisnotpossible tocoverthe openvisiblebone of leg and foot in one sitting. So he said, you try some other means of modalities. Then we opt for closed plaster treatment because we don’t have any other choice. We did wound debridement and K-wire fixation of metatarsal of foot and above knee POP cast application. K-wire removed at 6 weeks interval. Initial first month we had removed the old cast and reapplication POP cast at one week interval and from second month fifteen day interval or when POP is soaked whichever are early. After three month bone was completely covered with granulation tissue. We did skin grafting. In follow-up, wound was completely healed and child was completely walking with near normal gait at the end of two years of follow-up (Fig. 1). 5. Discussion Crush injuries of the limb are serious and can be difficult to manage. These complex injuries often involve soft tissue and osseous structures. Potentially devastating complications and long-term sequelae can occur if these injuries are under- estimated or mismanaged. Due to the high morbidity associ- ated with crush injuries, prompt and meticulous care is essential. Orr5 strongly condemns the closure of a wound communicating’ with a compound fracture on the grounds that in compound fractures generally it is virtually impossible to be sure that a wound is clean and to close it up (by suture) after no matter how thorough a mechanical cleansing and an antiseptic sterilization is usually to close up no little potential infection. Trueta6 advocates the closed method of treating war frac- tures. This was carried out by him as follows: (a) Excision of the all dead muscle and haematomata, (b) Reduction of the frac- ture, (c) Drainage of the wound with absorbent gauze, (d) Immobilization of the limb in plaster of Paris. By this means every possible attempt is made to prevent the growth of or- ganisms from the moment of wounding. The surgeon then has much better opportunity to eliminate infection by excision and debridement, even if undertaken well over the 8-h period. It is realised that a better line of treatment would have been immediate reduction of the fracture with a K-wire and coverage of wound with appropriate soft tissue. Unfortunately no such apparatus was available. Closed plaster method depended for its efficiency on physical and physiological ef- fects rather than its influence on the flora. This article reviews the characteristics of plaster of Paris and re-introduces the concept of tissue adaptation in response to the application of plaster of Paris splints and casts. Clinical examples of the use of plaster of Paris are dis- cussed. Such question should lead the reader to use plaster of Paris splinting or casting more often to solve clinical problem. It is recommended that a consultation with colleagues should a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 1 3 4 e1 3 6 135
  4. 4. always be held if it is decided to amputate a limb. One may conclude by stressing again the basic principle of adequate drainage and complete immobilisation in using the closed method; the importance of selecting cases and bearing mind the few contraindications to the closed plaster meticulous attention to detail in technique and after e care. Conflicts of interest The author has none to declare. r e f e r e n c e s 1. Billroth. Clinical Surgery. London: The New Sydenham Society; 1881. 2. Ollier L. Congress medical de France; 1872:192. 3. Morison Rutherford. Surgical Contraindication. vol. 1, pp 2 and 11. 4. Trueta J, Barnes. British Med J. 1940 July 13:46. 5. Orr Vinnett. J Bone Joint Surg. 1928;10:605. 6. Trueta j. Treatment of War Wound and Fractures. Hamish Hamilton; 1940. Fig. 1 e a and b: Preoperative photograph. c and d: during POP application period. e :photograph during skin grafting. f and g: after 3 months of skin grafting. h and i: photograph at the end of 2 years. a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 1 3 4 e1 3 6136
  5. 5. Apollohospitals: Twitter: Youtube: Facebook: Slideshare: Linkedin: Blog:Blog: