Basic Principles of Conservative Therapy
Conservative and surgical approaches to trauma management are equally important. There is no universal method in medicine, so the choice is always based on the advantages, disadvantages, and contraindications in each specific case.
Key conservative methods include:
- Postural management.
- Plaster immobilization.
- Continuous traction.
These methods can be used either independently or as adjunctive treatments. To enhance effectiveness, they are often combined with pain management, reduction of local inflammation, and stimulation of bone healing.
Postural management
This method involves fixing the damaged segment without external braces, plaster, or internal metal implants. It is important not to confuse this approach with the so-called functional method. The true functional method preserves mobility, whereas postural management requires strict rest.
Examples of Use:
- Stable pelvic fractures are often treated in the "frog-leg position" (knees bent and abducted, heels brought together).
- For stable compression fractures of the lumbar spine, the patient is placed on a special hyperextension roll with strict bed rest.
The main advantage of the method is the absence of the need to wear heavy fixing casts, which is especially beneficial for elderly patients and those with severe chronic conditions. The main disadvantage is the need for prolonged bed rest.
Soft bandages
Made of gauze, elastic fabrics, or manufactured as ready-made items. The most popular include Desault and Velpeau bandages, spiral («snake») bandages, triangular slings, figure-of-eight bandages, and Delbet rings.
Advantages:
- High patient comfort (lightweight, no hard pressure on bony prominences).
- Ability to visually assess the condition of soft tissues at any time.
Disadvantages and Limitations:
- Fixation is often insufficiently rigid.
- The bandage requires regular adjustment due to stretching or contamination of the material.
- The method is strictly contraindicated in patients with uncooperative behavior, as it requires strict discipline.
Plaster immobilization
Medical plaster of Paris is dehydrated calcium sulfate. When moistened, it forms a plastic mass that rapidly crystallizes. Despite technological advancements, plaster remains the optimal material. Hardening polymer bandages, although lighter, are significantly more expensive and, due to their high rigidity, can cause dangerous tissue compression if traumatic edema develops.
Rules for Handling Plaster:
- The bandage or multi-layered splint is immersed in water and left until air bubbles completely stop emerging, which means the material is fully saturated.
- The ideal water temperature is about 40 °C. In cold water, plaster hardens slowly, and in water that is too hot (boiling water), the hardening process may not occur at all.
- Crystallization involves an exothermic reaction (the cast heats up).
- Setting (loss of plasticity) takes a few minutes, while complete drying and maximum strength require from several hours to 1–2 days.
Important: any movement is prohibited until complete drying. Otherwise, cracks and folds will form on the flexion surface. This will lead to cast destruction, tissue compression, and deep pressure ulcers.
Outpatient care organization
The outpatient stage (trauma center) includes preparing the patient for hospital transport, treating minor injuries, and follow-up care for discharged patients. The structure of a modern trauma center includes reception rooms, X-ray, an operating room (for joint punctures and primary surgical wound debridement), a dressing room, and a plaster room.
The plaster room is equipped with a table for preparing splints, water basins, and specialized instruments for working with casts: plaster saws, knives, scissors, pliers, and spreaders. Specialized equipment, such as an orthopedic table or a Hoffman frame, may be required to apply complex stabilizing corsets.
Briefly: answers to topical questions
What types of plaster casts are used for limb immobilization?
There are non-padded and padded plaster casts, with splint and circular casts being the main types. Special variants of circular casts include splint-circular, split circular, fenestrated, bridged, hinged, as well as thoracobrachialis (thoracobrachialis), thoracocranialis (thoracocranialis), coxitis (coxitis), and corset casts.
What complications can arise from plaster immobilization?
Complications of plaster immobilization may include cast compression syndrome, local soft tissue necrosis, epidermal blisters (phlyctenae), peripheral neuritis, cast failure, secondary fragment displacement, and contact dermatitis. The most severe complication is cast compression, which can lead to total limb necrosis.
What are the types of continuous traction?
Continuous traction is divided into two main types: skeletal and skin traction. Skeletal traction involves applying traction directly to the bone using a metal pin, screw, or threaded rod. Skin traction is performed by attaching to the skin using medical adhesive, adhesive tape, or special soft cuffs.
What are the indications for skeletal traction?
Skeletal traction is one of the primary methods of fracture treatment with few contraindications. It is optimally used with constant application of heavy weights and also serves as an auxiliary method of preparation for surgery in femoral shaft fractures.
Temperature rule for plaster: cold water — process takes a long time, 40 °C — optimal (about 4 minutes), very hot water — the plaster will "cook" and fail to set.
Class and exam questions
What is the difference between positioning therapy and the functional method?
The functional method implies complete or partial preservation of movement in the injured segment, whereas postural management is strict immobilization (bed rest) without using casts.
Why haven't synthetic polymer alternatives completely replaced traditional plaster?
Polymer bandages lack sufficient plasticity and have high rigidity. As soft tissue edema increases, they can cause dangerous limb compression.
Why is it necessary to wait for air bubbles to stop rising when soaking plaster?
The cessation of air bubbles is a reliable sign that the plaster bandage is fully and evenly saturated with water.
Should hair be shaved before applying a unpadded plaster cast?
No, it is not necessary. The fear of severe pain due to hair sticking is exaggerated, as natural hair turnover occurs faster (about a month) than the removal of long-term immobilization.
What else to study on this topic
- Technique of Desault and Velpeau bandages: step-by-step algorithm.
- Fracture pain management and joint punctures at the outpatient stage.
- Complications of plaster immobilization: prevention of pressure ulcers and tissue ischemia.
- Design and application of the Hoffman frame and orthopedic table.
- Rules of primary surgical wound debridement (PSD) in a trauma center setting.
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