• The basis of treatment : “Continuing function while a fracture is uniting, encourages osteogenesis, promotes the healing of tissues & prevents the development of joint stiffness, thus accelerating rehabilitation.”It’s a closed method of treating fractures
Theoretical Basis• The fracture healing in FCB is mainly by External Bridging Callus formation.• Its has greater mechanical advantage over Medullary callus.• The intermittent loading of the # area, by muscle activity & weight bearing, promotes local blood flow & development of electrical fields which are beneficial for healing.
• The FCB allows movement at the joint & some movement at # site.• This transmits a measurable load which decreases as the # progresses to union.• The muscle compartments acts as a fluid mass surrounded by deep fascia.• Fluid is not compressible & fascia cannot be stretched beyond the confines of the cast.
• Thus after a certain degree of displacement, pressure & load is transmitted without further deformation.• This causes the bony fragments to be held more firmly.• Rotation is resisted by components of the brace.
When To Apply• Not at the time of injury.• Asses the # clinically.• Minor movements at the # site should be painless.
• Any deformity should disappear once the deforming force is removed.• There should be reasonable resistance to telescoping.• Shortening should not excede ¼ inch for tibia &1/2 inch for femur.
Contraindication• Lack of patients co-operation.• Patients with spastic disorders.• Deficient sensibility of the limb.• When the brace cannot be fitted closely & accurately.• Isolated tibial fractures.
FCB for Tibia fractures• Brace should be applied with in six weeks of fracture.• Make the patient sit on a couch with legs hanging over the edge.• Roll cast sock or stockinette onto the limb from the toes to above the knee.• Apply minimal cotton padding over the heel, tendocalcaneous, malleoli, tibial condyles & crest.
• With the ankle at right angle, apply POP bandages from the toes to 2 inches above the ankle & mould it.• Apply further POP from toes to the tibial tuberosity & mould it over the medial proximal half of the soft tissue of the calf.• Flex knee to 40 degrees & rest the patients heel on your lap.
• Apply further POP from the top of the cast to 2.5 cm above the proxmial pole of patella.• Firmly mould the plaster cast over the medial flare of the tibial & patellar tendon.• Apply pressure in the popliteal fossa & back of the calf with flat hand ,to produce a triangular cross-section in this area to help control rotations.
• Trim the upper end of the cast, keeping the ears as long as possible on both sides of the knee.• Posteriorly the upper edge of the cast is level with the tibial tuberosity.• Inferiorly the toes must be free to flex & extend fully.• Fit a walking heel slightly anteriorly to the long axis of the tibia.
FCB for Femur fractures• Long leg cast braces are mainly used for distal half of the shaft of the femur.• Coz of the tendency of the proximal third of the femur to go into varus.• Meggitt et al designed a hip-hinge thigh-cast brace for the management of such #.
• The thigh-cast extend distally to just above the knee.• Proximally – metal uniplanar hip hinge to a rigid pelvic band fitted to adjustable waist belt & shoulder strap.• Axis of the hinge-tip of greater trochanter in 20 degree of abduction at the hip.
• The standard long leg cast brace should be used only for the management of # of distal half of the shaft of femur & tibial plateau. And in obese patients.• Other types: 1) Knee-hinge cylinder cast brace. 2) Reducesd femoral cast brace.
How to apply long leg castbrace• Full extension of the knee & sufficient callus to prevent shortening must be present.• Pain & marked mobility at the # site must be absent.• Most # can be braced within 4-6 weeks of injury.
• Materials – plaster / thermoplastic material.• Four stages- 1) General preparation. 2) Below knee cast. 3) Thigh cast. 4) Fitting of knee hinges.
1 . General preparation;• Make the patient sit on a couch with approximately 6 inches of thigh exposed• Roll the cast socks from the toes to the groin• Apply minimal cotton padding over the heel , tendocalcaneous, malleoli , tibialcrest , condyles .
• With adhesive surface facing outwards apply a precut piece of orthopaedic felt over the tibial condyles .• Apply a second precut piece of orthopaedic felt over the femoral condyles .
• 2 . Below knee cast• With the ankle at right angle apply one 5 inch wide roll of orthoflex elastic plaster bandage from the base of the toes to within ¼ inch of the top of orthopaedic felt .• Cover the orthoflex with one 6 inch wide roll of zoroc resin plaster bandage .• Carefully mold the cast around the heel and ankle .
• 3. Thigh cast• Support the leg and exert slight traction on the limb maintaining the correct rotational position .• Heat the precut orthoplast cast in water bath at temp 72 to 77 degree C for 3 min , mop of the surface water and fit the cast snugly around the upper thigh up to groin
• Trim and smooth the upper edges of the cast• Apply a cold wet elasticized bandage over the orthoplast .• Mold the cast into quadrilateral shape by applying pressure with both hands .• Allow it to set .• The quadrilateral shape helps to control rotations .
• Firmly apply a 5inch roll of orthoflex elastic plaster bandage around the thigh from ¼ inch above the lower edge of orthopaedic felt to ½ inch below the top of cast brim .• Cover the orthoflex with one 6 inch wide roll of zoroc resin plaster bandage .• Mark the cast sock , the center of patella , the line of the joint , mid point of the limb on both medial and lateral aspect .
• 4. Hinges• Types – polyethylene or metal• Metal hinges must be positioned accurately using a jig .• Temporarily lock the metal hinges in extention and then fit them to the jig to hold them parallel .• Hold them at a level of middle of patalla and about 2 cm behind the midpoint of the limb on each side .
• Shape the arms of the hinges , so that it rests snugly against the cast .• Check the orientation of the hinges .• Clamp the lower end of the hinges to the below knee cast• Wile maintaining traction on the limb , push the thigh cast proximally and then clamp the upper end of the hinges to the thigh cast with jubilee clips .
• Plaster the ends of the hinges in to the casts above and below the clips then remove the clips and complete the attachment of hinges• Remove the jig and locking screws• Check the axis of movements in knee flexion as tolerated by the patient .• Finish off the lower end of the brace in similar manner .