A basic idea on Fracture types , POP tecniques and complications

1. FRACTURE TYPES , POP
TECHNIQUES AND COMPLICATIONS
Moderators :
Dr. Prabhu .B
Professor
Dr. Ramesh.R Presented By
Professor Dr. Venkatesh Ghantasala
Post graduate
Department Of Orthopaedics
J.J.M. Medical College- Davangere

2. TOPICS
1. Fracture Types And Classification.
2. Pop Techniques
3. Complications Associated With Pop
Techniques

3. FRACTURE TYPES AND CLASSIFICATIONS
1.1 PURPOSE OF FRACTURE
CLASSIFICATION SYSTEMS :
• To characterize fractures as far as certain general
and specific features.
• To guide treatment.
• To predict outcomes or prognosis
• To speak a common language with other
surgeons globally.

4. 1.2 HISTORY OF FRACTURE CLASSIFICATION :
•Fracture classifications have existed much longer than have
radiographs
•Edmund Smith Papyrus , though did not make a clear
distinction between comminuted and non-comminuted fractures ,
clearly classified fractures as open or closed , and provided
guidelines for treatment based on that classification.
•In the 18th and 19th centuries , still prior to the discovery of
radiographs , there were in existence fracture classification
systems that were based on the clinical appearance of the limb
alone
•Nearly all fracture classification systems in use today are
based upon on the analysis of plain radiographs of the
fractured bone.

5. 1.3 TYPES OF FRACTURE CLASSIFICATION SYSTEMS :
Classification systems used to characterize fractures can be
categorized into three broad categories :
1. Those that are fracture specific , which were generated for the
classification of a single fracture in a single location in the skeleton.
Eg: Garden classification of femoral neck fractures
Schatzker classification of proximal tibia fractures

6. 2. Those that are generic or universal fracture
classification systems , which apply a single, consistent
methodology to the classification of fractures in all parts
of the human skeleton.
Eg : The AO/OTA (Orthopaedic Trauma Association)
fracture classification of long bones is essentially the only
generic or universal system in wide usage today.

7. 3. Those based on soft tissue injury associated with
the fractures.
Eg : Gustilo and Anderson classification for open fractures
Oestern and Tscherne classification for closed fracture

8. GUSTILO AND ANDERSON CLASSIFICATION SYSTEM OF
OPEN FRACTURES

10. OESTERN AND TSCHERNE CLASSIFICATION SYSTEM OF CLOSED
FRACTURES
•Closed fracture grade 0 (Fr. C 0):
There is no or minor soft-tissue injury with a simple fracture from
indirect trauma.
A typical example is the spiral fracture of the tibia in a skiing injury.
•Closed fracture grade I (Fr. C 1):
There is superficial abrasion or skin contusion, simple or medium severe
fracture types.
A typical injury is the pronation-external rotation fracture dislocation of
the ankle joint: The soft-tissue damage occurs through fragment pressure
at the medial malleolus.
•Closed fracture grade II (Fr. C 2):
There are deep contaminated abrasions and localized skin or muscle
contusions resulting from direct trauma. The imminent compartment
syndrome also belongs to this group. The injury results in transverse or
complex fracture patterns.
A typical example is the segmental fracture of the tibia from a direct blow
by a car fender.

11. Closed fracture grade III (Fr. C 3):
There is extensive skin contusion, destruction of muscle or subcutaneous tissue
avulsion (closed degloving). Manifest compartment syndrome and vascular injuries
are included. The fracture types are complex.

12. 1.4 FRACTURE TYPES :
Definition :
A fracture is defined as a break in the continuity of the bone.

13. Based On Mechanism:
1.Traumatic Fracture – Fracture sustained due to trauma.
Eg .- Fractures caused by a fall , RTA.
2.Pathologic Fracture – A fracture through a bone which has been
made weak by some underlying bone disease.
Eg .- A fracture through a bone weakened by metastasis or
Osteoporosis.
3. Periprosthetic Fracture – A fracture at the point of mechanical
weakness at the end of an implant.

14. PATHOLOGICAL # PERI PROSTHETIC #

15. Based On Soft Tissue Involvement:
1. Simple/Closed fracture: Those in which the overlying skin and
soft-tissues are intact.
2. Open fracture/Compound fracture: Involve wounds that
communicate with the fracture, or where fracture hematoma is
exposed, and may thus expose bone to contamination. Open injuries
carry a higher risk of infection.

16. Based On Displacement:
1.Undisplaced : None or minimal displacement of fracture
fragments.
2.Displaced : Depending on fracturing force , muscle pull on the
fracturing fragments and the gravity, the displacement may be
Translation
Angulation
Rotatation
While describing the displacements of fracture ,
conventionally , it is the displacement of the distal fragment in
relation to the proximal fragment which is mentioned.

18. Based On Fracture Pattern:
1.Linear fracture : A fracture that is parallel to the bone's long
axis.
2.Transverse fracture: A fracture line is at right angle to the
bone's long axis. Caused by tapping or bending force.
3.Oblique fracture: A fracture that is diagonal to a bone's long
axis. Caused by bending force in addition to force along long
axis of the bone.
4.Spiral fracture: A fracture where at least one part of the
bone has been twisted. Fracture line runs spirally in more than
one plane. Caused by twisting force.

19. 5.Compression fracture/Wedge fracture: usually occurs in the
vertebrae , for example when the front portion of a vertebra in
the spine collapses due to osteoporosis where vertebrae
become brittle and susceptible to fracture, with or without
trauma.
6.Impacted fracture: A fracture caused when bone fragments
are driven into each other.
7.Avulsion fracture: A fracture where a fragment of bone is
separated from the main mass.
8.Segmental fracture : In this there are two fractures in one
bone , but at different levels

21. Based On Fragments :
1.Incomplete fracture: A fracture in which the bone fragments
are still partially joined. In such cases, there is a crack in the
osseous tissue that does not completely traverse the width of
the bone
2. Complete fracture: A fracture in which bone fragments
separate completely.
3. Comminuted fracture: A fracture in which the bone has
broken into several pieces.

22. PEDIATRIC FRACTURES :
•The anatomy and biomechanics of pediatric bone differ from
that of adult bone, leading to unique pediatric fracture
patterns , healing mechanisms , and management.
• In comparison to adult bone , pediatric bone is significantly
less dense , more porous and penetrated through out by
capillary channels . Pediatric bone has a lower modulus of
elasticity, lower bending strength , and lower mineral content .

23. •The low bending strength induces more strain in pediatric
bone than for the same stress on adult bone and the low
modulus of elasticity allows for greater energy absorption
before failure .
•The increased porosity of pediatric bone prevents
propagation of fractures , there by decreasing the incidence of
comminuted fractures.
•The pediatric periosteum is extremely strong and thick,
functioning in reduction and maintenance of fracture
alignment and healing.

24. Pediatric
Bone
Lower
Modulu
s Of
Elasticit
y
Highly
Porous
Lower
Bending
Strength
Greater
Energy
Absorption
Induces
More Stess
Prevents
Propagation
Of #

25. Pediatric Fracture Patterns :
1. Plastic Deformation or Bowing fracture
2. Torus OR Buckle fracture
3. Greenstick fracture
4. Complete fracture
5. Physeal fractures

26. •A force produces microscopic failure
on the tensile/convex side of bone
which does not propagate to the
concave side.

•The bone is angulated beyond its
elastic limit, but the energy is
insufficient to produce a fracture
•No fracture line is visible
radiographically.
•Most commonly seen in the ulna,
occasionally in the fibula.
•Bend in the ulna of < 20° in a 4 year
old child should correct with growth.
1. Plastic Deformation or Bowing fracture :

27. 2. Torus OR Buckle fracture
•Incomplete fractures of the shaft of a
long bone that is characterised by
bulging of the cortex.
•Compression failure of bone that
usually occurs at the junction of the
metaphysis and the diaphysis.
•They result from trabecular
compression from an axial loading
force along long axis of the bone.
•Distinct fracture lines are not seen.
subtle deformity o r buckle or a bump
of the cortex may be evident.
•Latin word tori which means
protuberance
•Heals in 3-4 weeks with simple
immobilization

28. 3. Greenstick fracture
•Bone is bent and the tensile/convex
side of the bone fails.
•Fracture line does not propagate to
the concave side of the bone, therefore
showing evidence of plastic
deformation.
•If the bone undergoes plastic
deformation, it is necessary to break
the bone on the concave side to
restore normal alignment, as the plastic
deformation recoils the bone back to
the deformed position.
• The name is by analogy with green
(i.e., fresh) wood which similarly
breaks on the outside when bent.

30. 5. Physeal fractures
•Fractures to the growth plate can be caused by i) crushing, ii)
vascular compromise of the physis or iii) bone growth bridging
from the metaphysic to the bony portion of the epiphysis.
•Damage to growth plate may result in progressive angular
deformity, limb-length discrepancy or joint incongruity.
•The distal radial physis is the most frequently injured physis.
•Most physeal injuries heal within 3 weeks. This rapid healing
provides a limited window for reduction of deformity.
• Physeal injuries are classified by the Salter-Harris (SH)
classification system, based on the radiographic appearance of
the fracture.

32. Corner Fracture Or Bucket-Handle Fracture :
•A corner fracture or bucket-handle fracture is fragmentation
of the distal end of one or both femurs , with the loose piece
appearing at the bone margins as an osseous density
paralleling the metaphysis.
•The term bucket-handle fracture is used where the loose
bone is rather wide at the distal end , making it end in a
crescent shape.
•These types of fractures are characteristic of child abuse
related injuries

33. Fractures With Eponyms :
Few fractures have eponyms. Few are named after the person who
demonstrated first and few are named according to the mode of
injury.
1. Arm
•Holstein-Lewis Fracture – A fracture of the distal third of the
humerus resulting in entrapment of the radial nerve.

34. 2. Forearm
•ULNAR FRACTURES
1.Monteggia Fracture dislocation –
A fracture of the proximal third of the ulna with
the dislocation of the head of the radius. It may be of
extension type or flexion type depending on the angulation
of ulna.

35. 2. Hume Fracture –
A fracture of the olecranon with an
associated anterior dislocation of the radial head

36. 3.Night Stick Fracture –
Isolated fracture of the shaft of ulna sustained while trying to
ward off a stick blow.

37. •RADIUS FRACTURES :
1. Essex-Lopresti Fracture – A fracture of the radial head with
concomitant dislocation of the distal radio-ulnar joint with
disruption of the interosseous membrane.

38. 2. Galeazzi Fracture:
A fracture of the lower third of radius with
dislocation or subluxation of the distal radio-ulnar joint.

39. 3. Colles' Fracture :
Fracture of the distal end of the radius at its cortico-
cancellous junction with various types of displacements of
distal fragment , accordingly it may be -
Impaction of fragments
Dorsal displacement
Dorsal tilt
Lateral displacement
Lateral tilt
Supination

41. 4. Smith's Fracture :
Fracture of the distal end of radius at its
cortico –cancellous junction with dorsal fragment being
displaced ventrally or tilts ventrally.

43. 5. Barton's Fracture :
An intra-articular fracture of the distal radius with dislocation of
the radiocarpal joint. Depending on the extension of fracture line
to either of the anterior or posterior cortices. It may be
a. Volar barton(anterior marginal type)
b. Dorsal barton (posterior marginal type)

45. Dorsal Barton

46. Volar Barton

47. 6. Chauffeur Fracture :
An intra articular oblique fracture of styloid process of radius.

48. 7. Side-Swipe Fracture OR Baby Car Fracture :
It is a combination of fractures of distal end oh humerus with the
fractures of proximal ends of radius and/or ulna. Sustained when
one’s elbow projecting out of a car, is side swept by another
vehicle.

49. 3. HAND
1. Rolando Fracture - A comminuted intra articular fracture through
the base of the first metacarpal bone.

50. 2. Bennett's Fracture –
An oblique intra-articular fracture of the
base of the first metacarpal bone with subluxation or dislocation of
the metacarpal. Fracture line extends into the carpo-
metacarpal (CMC) joint.

51. 3. Boxer's Fracture -
A fracture at the neck of a metacarpal.
Commonly 5th metacarpal sustained when a closed fist hits against
a hard object.

52. 3. Mallet Finger Or Base Ball Finger –
A finger flexed at the DIP joint due
to avulsion or rupture of extensor tendon at the base of distal
phalynx resulting from sudden passive flexion of DIP joint.

53. 4. TIBIA :
1. Pilon Fracture - Comminuted intra articular fracture of distal
end of tibia.

54. 2. Bumper Fracture -
A fracture of the lateral tibial plateau
caused by a forced valgus applied to the knee.

55. 3. Segond Fracture -
An avulsion fracture of the lateral tibial condyle.

56. 4. Gosselin Fracture -
A fractures of the tibial plafond into anterior and
posterior fragments
5. Toddler's Fracture -
An undisplaced and spiral fracture of the distal
third to distal half of the tibia seen in toddler age group of 9 months
to 3 years.

57. 5. Fibula
1.Maisonneuve Fracture -
A spiral fracture of the proximal third of the
fibula associated with a tear of the distal tibiofibular syndesmosis
and the interosseous membrane.

58. 3. Bosworth Fracture-Dislocation -
A fracture with an associated
fixed posterior dislocation of the proximal fibular fragment which
becomes trapped behind the posterior tibial tubercle. The injury is
caused by severe external rotation of the ankle.

59. 2. Le Fort Fracture Of Ankle -
A vertical fracture of the antero-
medial part of the distal fibula with avulsion of the anterior
tibiofibular ligament

60. 6.Combined Tibia And Fibula :
1. Pott’s Fracture-
Bimalleolar ankle farcture - involving the
lateral malleolus and the medial malleolus.

61. 2. Cotton’s Fracture-
Trimalleolar ankle fracture - involving
the lateral malleolus, medial malleolus and the distal posterior
aspect of the tibia.

62. 7.Foot
1. Lisfranc Fracture -
In which one or all of the metatarsals are displaced from
the tarsus. The articulation between fore foot and mid foot is
referred to as lisfranc joint.

64. 2. Jones Fracture -
A fracture of the base of the fifth metatarsal
bone.

65. 3. March Fracture -
A fracture of the distal third of one of the metatarsals
occurring because of recurrent stress.

66. 4. Aviator’s Fracture –
Fracture of the neck of the talus.

67. 5..Chopart Fracture-Dislocation –
A fracture dislocation of the mid tarsal
joints i.e talo-navicular and calcaneo-cuboidal joints. The
articulation between hind foot and mid foot is commonly referred
as chopart joint and hence the fracture name.

68. 8.Pelvis :
1.Duverney Fracture - An isolated pelvic fracture involving only
the iliac wing.
2.Straddle Fracture- Bilateral superior and inferior pubic rami
fractures
3.Malgaigne’s Fracture- A type of pelvis fracture in which
there is combination of fractures, pubic rami anteriorly and
sacro-iliac joint or ilium posteriorly on the same side.

69. 9.Hip
Dashboard Fracture –
Fracture of the posterior lip of acetabulum often
associated with posterior dislocation of hip.

71. 10.Spine
1. Jefferson Fracture :
Fracture of the anterio and posterior
arches of the C1 vertebra

72. 2. Hangman's Fracture-
Fracture of both pedicles or pars
interarticularis of the C2 vertebra with or without subluxation of
C2 over C3 sustained in hanging.

74. 3. Flexion Teardrop Fracture –
Posterior ligament disruption and anterior
compression fracture of the verterbral body which results from
a severe flexion injury.

76. 4. Clay-Shoveler Fracture –
Fracture through the spinous process of
a vertebra occurring at any of the lower cervical or upper
thoracic vertebrae.

78. 5. Burst Fracture -
Comminuted farcture of the vertebral body in
which atleast two columns are broken from a high-energy axial
load.

79. 7. Chance Fracture –
 Compression injury to the anterior portion of a vertebral body
with concomitant distraction injury to posterior elements.
It is a three column injury with a horizontal orientation of the
fracture. Also called seat-belt fracture.
The classic mechanism of this injury is a lap-belt injury.
If you don't have an addtional shoulder belt, the body will fold over

81. 9.Translational Injuries -
 They are associated with shearing forces that disrupt all
three columns.
The shearing forces are most often directed posteriorly to
anteriorly but may also be directed anteriorly to posteriorly.
 Since the ligament of the spinal canal is affected, these
injuries are always unstable and are associated with a very
high incidence of neurologic deficit.

82. 2. POP(PLASTER) TECHNIQUES
PLASTER OF PARIS
HISTORY:
•Hippocrates in 350 B.C. used bandages stiffened by waxes and
resins.
•The ancient Egyptians used wooden splints made of bark
wrapped in linen.
•Ancient hindus treated fractures with bamboo splints
•In 13th century POP was used for walls in England.

83. •Cheselden , an English surgeon in the 18th century used bandages
soaked in egg white and flour to form a cast.
•NILOLAI IVANOVICH PIRIGOV (1810-1881) Plaster of paris
dressings were first employed in the treatment of mass
casualities in the 1850s during Crimean war.
•Koyle & kluge from berlin in 1828 used box-casts.
•The name POP was derived from an accident to a house built on
a deposit of Gypsum, near Paris.
•The house burnt down. When rain fell on baked mud of the
floors it was noted that foot prints in mud set rock hard.

84. CHEMICAL FORMULA :
2CaSO4·½H2O + 3H2O ==> 2CaSO4·2H2O + heat
Hemi hydrated calcium sulphate Hydrated calcium sulphate
(POP) (GYPSUM)

85. HOW IS POP
PREPARED ??
POP is
made from
crystalline
gypsum by
heating in
controlled
conditions
(120o – 160o
C) in a
steam
autoclave.
The
powder is
treated in
a solvent
with
various
additives.
The
suspensio
n is
coated
into a
special
interwove
n cloth
called
LENO.
The
bandages
are cut and
rolled in a
moisture
free
containers

86. ORTHOPAEDIC USES OF POP :
• To support fractured bones
•To stabilize joints in ligamentous injury
•To immobilize joints and limbs after surgery.
•To correct deformity as in CTEV
•To make a negative mould of a part of body for construction
of an orthosis or prosthesis.

87. USED IN 4 FORMS MAINLY :
• Slab
• Cast
• Spica
• Functional Cast Brace.

88. RULES OF APPLICATION OF POP :
•Choose the correct size of the roll
• A joint above and a joint below the fracture/injury should be
included.
•Plaster should not be too tight or too loose.
•Padding should be from distal to proximal with 50% overlap, with
extra padding over bony prominences like malleoli, patella,
olecranon and fibular head

89. •Moulding should be done with palm not with fingers to avoid
indentations.
•A cast should never be applied carelessly with the thought in
mind that it can be changed next month if it turns out to be
imperfect one.
• One should apply a plaster with the idea that it might be made to
last for the whole period of treatment.

90. PADDING :
•1-2 layers or more depending on the amount of swelling.
•Extra over elbows and heels.
•Be generous over bony prominences.
•Always pad between digits when splinting hands/ feet or when doing buddy
strapping.
•Avoid wrinkles and lumps.
•Not to be applied tightly- danger of ischemia !!
•Just before completion of plaster application make sure that padding
material(cotton ) is turned back and loose edges are secured with a turn
or two of plaster bandage if cast is applied ; and with encircling gauze
bandage in case of slab application.

91. STOCKINET :
•It protects skin and makes the bandge application looks
nifty.
•To be applied on the skin before the padding is done.
•Always cut the stockinet longer than the splint to be applied.
•Available in 2,3,4,8,10,12 inches width.

92.  Setting time : Time taken to change from powder form to
crystalline form.
 Drying time : Time taken to change from crystalline form to
anhydrous form.
 Average setting time : 3-9 minutes.
 Average drying time : 24-72 hours.

93. FACTORS DECREASING SETTING TIME :
 Hot water
 Salt
 Borax
 Resin
FACTORS INCREASING SETTING TIME :
 Cold water
 Sugar

94. BASIC PLASTERING TECHNIQUE :
• Palstering is a form of craft.
• Skill not to be learned from books but by continuous
practice.
• A good manipulative reduction can be spoiled due to a clumsy
plaster application.

95. SLAB :
•Slab is a temporary splint made up of half by POP and half by bandage roll.
•Used in initial stages of fracture treatment, during first aid and to immobilize
the limbs post operatively.
Steps in application of slab –
•Slab is measured into required length
•For upper extremities use 8-10 layers and for lower extremities use 12-15 layers or upto
20 depending on size of the person
•Trimmed to the requirement of of the area of application
•Slab held carefully at both ends and immersed completely in tepid water.
•Lift out and momentarily bunch up at an angle to expel excess water.
•Consolidate the layers of the slab to remove excess of air as retained air causes reduction
of plaster strength.
•Slab is positioned and smoothened out with the hands so that the slab fits closely
to the contours of the limb.
•Wet bandage is applied to avoid tightening from shrinkage after coming in contact with
the slab.

96. Below Elbow Slab:
Indications –
•Wrist fractures
•Metacarpal fractures
•Colle’s fracture
Extends from a point about 5 cm below the top of the olecranon or
2 fingers breadth distal to elbow crease to the level just proximal to
the knuckles in the dorsum of the hand and the distal crease in the
palmar aspect.
The forearm is held with the elbow in a 900 flexed and the wrist in
the position of function of 250 dorsiflexion for wrist fractures.
The fingers should be free to move fully at the metacarpo-
phalangeal joints.
Wrist in 40-45 degrees of dorsiflexion and MCP joints in 90 degrees
and IP joints in full extension (cock-up position) for metatarsal
fractures.

97. Above elbow slab in elbow flexion :
Indications
•Fracture both bones forearm
•Supracondylar # humerus of extension type
•Unstable proximal radius or ulnar #
Above elbow slab in elbow extension :
Indications
•Olecranon #
•Supracondylar # humerus of flexion type.
Extends from the middle of the upper arm to the point just
proximal to the knuckles in the dorsum of the hand.
patient's forearm is held in mid prone position with the elbow in
900 flexed position or full extension depending on the type of
fracture.

98.  U SLAB OR COAPTATION SLAB :
Indications :
For Proximal and shaft of humerus fractures.
Applied to the medial and lateral aspects of the arm, encircling
the elbow and overlapping the shoulder.
Utilizes dependency traction and hydrostatic pressure to effect
fracture reduction

99. Below knee slab
Indications:
•Ankle fractures and dislocations post reduction
•Tarsal and Meta tarsal fractures.
Position :
Proximal end – upto tibial tuberosity.
Distal end – upto MTP joints of foot.
Foot in neutral position.

100. Above Knee Slab
Indications
• Proximal and mid shaft Tibial fractures.
•Supra condylar # of femur
Proximal end – as high in the groin as possible
Distal End – to mp joints of foot
Knee in 5 to 15 degrees flexion
Foot in neutral position

101. CAST :
•In this form of splinting POP roll completely encircles the limb.
•Casting is used as a definitive form of fracture management and
also to correct deformity.
Steps in application of cast :
• After stockinet application and tidy , uniform padding select the
appropriate width of POP roll to be applied (generally 4 inch or 6
inch)
•Dip the roll in tepid water completely.
•Secure the end of bandage to prevent it from getting lost.
•Hold the bandage lightly with the other hand without compression.

102. •Immerse at an angle of 45o
•Keep under the water until bubbles start rising.
•Remove the excess water by compressing in axial direction.
Depending on the amount of
padding , plaster casts are divided broadly into 3 types:
 Badly padded plaster
 Unpadded plaster
 Padded plaster.

103. Badly padded plaster :
• Bohler advocated this plaster application.
• It is loose on the limbs and cannot fix fragments.
Unpadded plaster :
• Pop bandage directly applied to skin without intervention of any
textile.
• Advocated by Bohler.
• Believed to enhance the fixation of fractures.
• For practical purposes, if stockinet is used the resulting plaster can
still be regarded as an unpadded cast.

104. •The bandage is made to roll itself round the limb.
• The closeness of its application to the limb and actual adhesion
to the skin is believed to enhance fixation of fragments.
•Bandage should never be pulled tight.
•Should be applied by laying the wet roll of plaster on the skin
and pushing it round the curves of limb with flat of hand.
•The roll of plaster should not be lifted off the limb and
pulled.

105. Padded plaster :
• Advocated by Bologna school
•Layer of cotton wool is interposed between the skin and
plaster.
•Cotton applied as an even layer of rolled wadding.
•The elastic pressure created by cotton enhances the fixation
of limb by compensating for shrinkage of tissues.
•The care with which cotton is applied is essential for
success.
•The cotton should not obscure the shape of the limb by
being put in careless and ugly lumps.

106. • Bandage is pressed and pushed round the limb by the pressure
of the thenar eminence under a strong pushing force directed in
length of surgeons forearm.
• Pressure is applied at the middle of the bandage so that no
excess of pressure can fall on either edge.
•Each turn is applied slowly and is settled carefully in position.
• At tapering parts of the limb the turns are made to lie evenly by
small tucks which are made with quick movement of index finger of
left hand.
• The hall mark of good plaster is that it should be of even thickness
from end to end

107. Two person team

108. . Materials (prepared before the procedure)

109. . Positioning of the limb

110. Application of the padding

111. Handling of plaster bandages

112. Application of plaster bandages

113. Final Manipulation Is Done And The Reduction Held, With
Appropriate Molding, Until The Plaster Hardens.

114. During the evaporation period, the casted limb should
remain exposed and not fully covered by blankets.

115. TRIPLE SEQUENCE IN PLASTER APPLICATION :
Phase 1 : Examination And Rehearsal
Phase 2 : Plastering
Phase 3 : Reduction And Holding

116. Phase 1 : Examination And Rehearsal
• Examination of the displacement and assessment of the forces
required to reduce and hold the reduction.
• Need to assess effect of gravity on the displacement.
• Range of excursion from the position of greatest deformity to
the position of apparent reduction.

117. Phase 2 : Plastering
• Limb held by assistant in position of approximate reduction.
• Surgeon himself should apply the bandage.
• Quick application is more important than holding precise
reduction.
• Plaster should still be completely soft after completion to allow
final touches

118. Phase 3 : Reduction And Holding
•After applying sufficient plaster , surgeon prepares to apply the
rehearsed movement of reduction.
•Should be able to clearly recognize sensation of reduction.
•After applying rehearsed reduction, surgeon holds on, without
further movement to allow the cast to set.
•In the last few minutes, he should obliterate any abrupt
impression that might invite pressure sores.
•NOT TO FORGET CHECK XRAY should be done after
application of each cast to confirm the acceptability of reduction.

119. FUNCTIONAL CAST BRACE :
•Advocated by August Sarmiento
•It is a non surgical method of fracture treatment in which
hydraulic action of the muscles is used to hold the fragments in
alignment using a brace.
•A well fitting plaster cast is applied and the patient starts using
the extremity i.e. allowed to walk on the cast. Muscle action
and the intermittent axial compression stimulates bony union.
•Not suitable for fresh fractures.

120. •Suitable for fractures of tibia and femur and selected stable
upper extremity fractures.
• Care should be taken to correct any angular or rotational
deformity upon the position of the fragments before the brace is
applied.
• A period of immobilization in a conventional cast is required
Pre- requisites :
• Minor movements at the fracture site should be painless.
• Any deformity should disappear once the deforming force
is removed
• Shortening should not exceed 6mm for tibia and 1.25 cm
for femur.
• Reasonable resistance to telescoping.

121. SPICA :
A cast of layers overlapping in a V pattern, covering two body
parts of greatly different in size, as the hip and waist, thumb
and wrist, etc.
Eg : Hip spica cast
Thumb spica cast

123.  Advantages Of POP :
•Cost effective
•Non allergic
•Easily moulded to different forms.
 Disadvantages of POP :
•Radio-opaque , may occlude # lines
•Heavy
•Easily breaks when comes in contact with water.

124. AFTER CARE OF POP :
• Keep the plaster cast dry.
• Mobilize all the joints which are not incorporated in the plaster to
their full range of motion once it becomes dry.
• Come immediately if any of the following symptoms develop
Excessive pain
Excessive swelling
Bluish or white discoloration of fingers or toes
•Notice any cracks in the plaster.
•Graduated weight bearing for lower limb #
•Physiotherapy of muscles within the plaster and joints outside
the plaster is necessary to ensure early rehabilation.

125. WELLINGTON BOOT EFFECT :
In below knee plasters it is important that bandage should be
pulled very tight in the proximal part because, unless the wool
and the soft muscles are both powerfully compressed it will be
found that plaster when completed will be as loose as the
wellington boot.

126. 3. COMPLICATIONS OF POP
Due to tight cast
•Pain
•Pressure sores –
The patient’s complaints of a painful cast should never be ignored,
and the cast should be changed promptly.
 Often, this may reveal an area of early skin pressure or irritation
that could progress to full-thickness skin loss.
Compartment syndrome and the resulting sequelae Volkmann's
Ischaemic contracture.
• Peripheral nerve injuries

127.  Due to improper applications :
• Joint stiffness and malposition of limb.
• Plaster blisters and sores.
 Due to plaster allergy :
• Allergic contact dermatitis –
 The skin symptoms of irritation were all mild and temporary.
Quaternary ammonium compound BENZALKONIUM CHLORIDE
is the allergen responsible for plaster of Paris-induced allergic
contact dermatitis

128.  Disuse Atrophy and Muscle Weakness –
• Muscles that do not function when under cover of plaster will
atrophy
• Not only can this result in cast loosening, but there may also be
functional loss.
• Motion and isometric exercises should be encouraged.
• Prolonged non–weight-bearing treatment in a cast can also
result in disuse osteopenia, which can complicate recovery.
• Typically, radiographic features include loss of trabecular
pattern, a speckled or mottled appearance of the periarticular
surface, and a generalized “WASHED-OUT” appearance

129.  PLASTER DISEASE :
 When a limb is put into POP and the joints immobilized for
a long period , joint stiffness, muscle wasting and osteoporosis
are unavoidable.
 This syndrome can be reduced to a minimum by the early
use of functional braces, isometric exercise and early weight-
bearing. These in turn promote a rapid retrieval of function.

130.  FRACTURE DISEASE :
• A constellation of symptoms and physical changes has been
called “fracture disease.”
• Prolonged immobilization, especially in a nonfunctional cast, can
lead to a vicious cycle of pain, swelling, and unresolved edema.
• Edema fluid is a proteinaceous exudate that will congeal and
gets converted to a gelatinous material and deposited as a scar
tissue around joints and tendons causing joint stiffness,
contracture and tendon adhesions.
• Muscle atrophy, brawny skin /induration, and osteoporosis
follow
• Reflex sympathetic dystrophy may sometimes occur and
further complicate the picture

131. CAST SYNDROME :
• Cast syndrome is a rare complication that is seen related to body jacket,
shoulder spica, and hip spica
• The syndrome occurs due to arteriomesenteric duodenal obstruction, and it
is a result of excessive abdomen and chest coverage.
• Symptoms are severe, and if left untreated, can be potentially lethal.
• Compression of the third part of the duodenum between the lumbar spine
and the aorta posteriorly and the mesentry and vessels anteriorly.
• This syndrome is precipitated by recumbency and increased lumbar lordosis.
• Avoiding constrictive body casts that increase lumbar lordosis prevents cast
syndrome.
• Nausea, epigastric fullness, and regurgitation should be carefully evaluated.

132. SPECIAL BANDAGES :
POP bandages prepared on elastic gauze instead of cotton
cloth. These bandages can stretch when wet to suit the shape of
limb.
E.g. ORTHOFLEX - Orthoflex Elastic Plaster Bandages are ideal for
difficult casting procedures such as post-amputation, as they
conform well to body contours and bony prominences.
Sets fast in 5 - 8 Minutes.

133.  FIBRE GALSS CAST :
• A fiberglass cast is a lighter, synthetic alternative to the more
traditional plaster version.
• It is created by padding the extremity with cotton or waterproof
padding material, followed by wrapping several layers of knitted
fiberglass bandages impregnated with a water-soluble, quick-
setting resin
Advantages :
•Short setting time
•Immediate weight bearing
•Strong but weighs light
• Radiolucent
•Water resistance
•Wicks moisture better

134. Disadvantages :
• High cost
• Can’t be applied over wet wounds or immediately after trauma
• Difficult to remove
• Leaves sharp edges
• Less mouldable
 POLYMER RESIN CASTS:
Bandages of cotton, fibre glass or polypropylene
impregnated with resin which hardens on contact with water.
Rapid setting and water resistance combined with porosity and
radiolucency.

135. THERMOPLASTICS :
Plastics which are pliable when heated and hardened when cooled.
This property helps to modify casts or splints.
• Low temperature thermoplastic splints can be softened in hot
water and placed directly on the skin and are most appropriate for
upper limb fractures or injuries.
• High temperature thermoplastic splints are made from a cast and
require higher temperatures and a longer curing time to harden.
These splints are better suited for lower limb or back injuries that
generally require a longer healing period

137. CORTEX EXOSKELETON….
• Latest potential application of advanced materials manipulation.
•Cortex Exoskeleton concept addresses those factors using
advanced 3D printing techniques.
•An X-ray of the fracture is combined with a 3D scan of the limb,
and then a custom sleeve is printed, complete with extra
“membrane” structuring around the exact point of the injury.

138. IDEAL CAST :
•Suitable for direct application
•Easy to mould or remould
•Nontoxic for patient
•Unaffected by water
•Transparent to x-rays
•Quick setting
• Able to transmits air, water, odour and pus
•Strong but light in weight
•Non-inflammable
•Non messy application and removal
•Long shelf life
•cheap