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.

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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: drpankaj06@yahoo.co.in, drpankaj06@gmail.com.
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/apme
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.
http://dx.doi.org/10.1016/j.apme.2013.05.014

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. 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

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