TRAUMA CARE AND MANAGEMENT
With any traumatic musculoskeletal injury, x-ray films of the injured area are taken to determine the injury and its extent, such as a fracture and the resulting positions of bone fragments. A portable high-quality video machine is available to make the first determination of fracture. Such machines help in sports injuries because they can be carried onto the playing field before the injured person is moved.
The treatment objective is to restore the bone to natural alignment to ensure proper healing. The method chosen depends on the location and extent of the break and the client’s condition and age. The fragments must be brought back into place (reduction) and held in that position (immobilization) until the broken parts heal. The two types of reduction are closed and open. In closed reduction, external manipulation realigns the bone ends; in open reduction, surgery accomplishes the realignment.
Different types of immobilization devices may be used, including casts, internal and external fixation, splints, and traction. The use of computers helps determine the exact type of prosthesis or reconstruction needed in some cases.
Many healthcare facilities have a special cast-and-splint room. In large facilities, specialized technicians work in this area. If the nurse is asked to assist, the healthcare provider will specify the desired cast or splint material to be used and will direct its application.
Often, clients receive analgesics or anesthetics before cast application; medications are given less frequently for splint application. If a general anesthetic is used, the immobilizing device is applied in an operating room or day-surgery center. Give routine preoperative and postoperative care.
Special Considerations: LIFESPAN
Casts
Sometimes, older clients with casts do not move sufficiently to counteract the dangers of hypostatic pneumonia. Encourage deep breathing exercises and the use of an incentive spirometer as a good preventive measure. Older persons may have difficulty learning to use crutches or other mobility aids safely.
Splints
Immediately after an injury, a temporary splint is necessary to immobilize the affected body part before treatment begins or until swelling subsides. Splints are also used for therapeutic purposes.
A common splint is the half-cast, in which a full cast is applied, then sawed in half lengthwise (bivalved). The bottom half of the cast may be used alone, or both halves may remain in place. Half-casts are held in place with an elastic roller bandage, which may also be used alone after healing begins, to give support. The half-cast may be taken off at intervals and reapplied, or it may remain in place for the full period of immobilization.
Another type of splint is the inflatable splint, consisting of a plastic bag that is inflated inside a second plastic bag with a zipper on one side. Although they are most often used in emergency first aid, acute care facilities also use inflatable splints. These splints are available in different sizes to fit various body parts, including the leg, ankle, and arm.
If an inflatable splint is to remain in place for some time, loosely apply a light stockinette to the affected extremity. Apply the splint, zip it, and inflate it just enough to immobilize the part. This splint is comfortable because it is lightweight. It is also convenient for healthcare personnel to use because it is transparent and does not need to be removed when x-ray films are taken. Be careful not to puncture an inflatable splint.
Other splints include Thomas or ring splints (which may be used in combination with traction), molded aluminum splints, and other metal splints. Nursing care of a client in a splint is similar to that of a client in a cast.
Nursing Alert Never ignore a complaint of pain or pressure from a person wearing a cast or splint. Check the extremity’s circulation, motion, and sensation (CMS), elevate the extremity, and report the situation immediately.
Casts
A cast is a solid mold that is used to immobilize a fracture, relieve pain through rest, and stabilize an unstable fracture. The cast remains on the affected area until the bones have rejoined, a process called fusion. A cast may be applied in a client’s room, Emergency Department, Operating Room, physician’s office, or clinic. Nurses may be asked to assist with cast application. Specific in-service training is usually required (see In Practice: Nursing Care Guidelines 77-1).
IN PRACTICE: NURSING CARE GUIDELINES 77-1
PREPARING FOR CASTING
• Gather all materials beforehand, including a stockinette and padding materials. Be sure a source of water is available.
• Follow the manufacturer’s instructions regarding preparation.
• Wear gloves if the fracture involves blood and to protect your hands from the casting materials.
• Prepare the injured area. In many cases, wash the area (without soap), carefully dry it, and shave it. Apply an astringent or alcohol if ordered.
• Lubricate the area, as ordered.
• Have sterile dressings available for an open (broken-skin) compound fracture.
• Position the client as directed.
• Assist or restrain the client, as needed.
• Reassure the client during the procedure.
• Be aware that a follow-up x-ray examination is necessary after the cast is applied. Ensure that the client is comfortable.
• Clean up immediately after the procedure, before the cast or splint material hardens and becomes difficult to remove. A special sink with a plaster trap is usually available. Do not put plaster or cast material in a regular sink.
Types of Casts
Casts are typically made of plaster or a synthetic material such as fiberglass. Although fiberglass is lighter in weight, longer wearing, and allows better air circulation than plaster, plaster is less expensive than fiberglass and, in some cases, can be molded better into the desired shape. Both materials come in strips or rolls that are immersed into water and applied over a layer of cotton or synthetic padding covering the injured area.
Plaster Cast. A plaster cast requires proper care so that it immobilizes the injured part without causing further damage or injury. A large plaster cast remains wet for 24 to 48 hours. Because the cast must dry in its applied shape, support it with pillows to preserve the original contours. Keep the cast uncovered, and turn the client so that all sides of the cast will dry. Turning also helps prevent other complications.
Handle the wet cast with palms only, not with fingers. Rationale: Finger pressure can dent a cast, creating pressure points. Move the client’s extremity by grasping either side of the casted area. Do not grasp the cast unless absolutely necessary. In some instances, a cast dryer may be used. However, take care not to apply intense heat because it could burn the client, crack the cast, or dry the outside of the cast while the inside stays wet and becomes moldy.
The client may complain of being cold while the cast is drying. Cover the rest of the client’s body with a blanket and prevent drafts. If the weather is hot, the client may complain of being too warm. Cool liquids and a cool cloth applied to the forehead may help. If necessary, lower the room temperature slightly. Ice packs can be applied around the cast to offset the heat the drying plaster emits.
If a cast’s edges are rough, cover them with tape, a procedure called petaling. If a stockinette is placed inside the cast, cover the rough edges by pulling the edge of the stockinette out, folding it over the cast’s edge, and taping it in place. Doing so can help prevent irritation to the extremity caused by plaster crumbs and rough cast edges.
Protect a cast applied near the client’s genital area against moisture. Even after a plaster cast dries, it must not become wet or the plaster will dissolve.
Synthetic Cast. Light synthetic casting materials, such as fiberglass, are often more convenient to use than are plaster casts. Most casts applied to the extremities are fiberglass. They are sometimes more durable, and take less time to dry, drying in approximately 15 minutes. Synthetic casts are lighter and stronger than plaster casts. Some synthetic casts can be exposed to some water. X-ray films can be taken through this material. However, there is no give to these casts, and some clients cannot tolerate them.
Key Concept If a cast or splint becomes dented, softened, or broken, it will not serve its purpose: immobilization of a body part.
Caring for Clients in Casts
In Practice: Nursing Care Guidelines 77-2 and In Practice: Educating the Client 77-2 provide fundamental information for the nurse, the client, and the family about cast care.
Cast Removal
Casts are removed with a cast saw, which oscillates back and forth, although it appears to rotate. The blade moves only a fraction of an inch and will not cut the client. Because cast removal can be frightening, explain the procedure and show the client the cast saw before removal begins. A client who realizes that cast removal is safe will be better able to tolerate the noise and dust. Wear gloves, protective eyewear, and a mask to avoid irritation and inhalation of small dust particles.
Before a cast is removed, explain to the client that the skin under the cast may be covered with scales or crusts of dead skin. Also inform the client that muscles may appear atrophied and that the limb may be weak or stiff. After cast removal, the client may wear a brace for a week or two to provide additional stability to the injured area. All healthcare team members (e.g., physician, nurse, physical therapist) will instruct the client about therapeutic exercises for the affected body part.
Traction
Another means of immobilization is traction, which may be used with other types of immobilization, such as surgical internal fixation. Traction exerts a continuous pulling force on broken bones to keep them in the natural position for proper healing. In traction, continuous pulling force is controlled through the use of weights; a physician determines how much weight to apply by using principles of physics. The strength of the traction forces (weights) on the bones must be sufficient to counteract the overall pull of the body’s muscles. The location and number of pulleys help determine the direction and degree of the pull. Countertraction forces pull against traction forces and may be produced with weights, bed position, or the client’s body weight. An overhead frame attached to the bed holds the traction pulleys and equipment in place. A trapeze may also be attached to the bed so the client can pull his or her head and shoulders off the bed. With any type of traction, never remove or change the weights on any traction device without a physician’s order.
Skin Traction
In skin traction, the pull is applied to the client’s skin, which transmits the pull to the musculoskeletal structures. Skin traction, such as Bryant’s or Buck’s extension traction, is typically left on for shorter periods of time than skeletal traction, often for 3 weeks or less. A belt, head halter, foam rubber wrapped with an elastic bandage, or a foam boot is applied to the client’s skin before the appendage is attached to traction. A disadvantage of skin traction is that it can provide only 8 to 10 lb of pull.
Irritation and breakdown of the skin are complications. Skin traction may be supplemented or replaced entirely by physical therapy and medications for muscle spasms. It is often used for children, minor fractures in adults, muscle strains or spasms, and temporary traction for adults with a hip fracture. If skin traction is being used to immobilize a fracture, the traction is left on. However, if skin traction is used to minimize muscle spasms, the healthcare provider may allow for periods without traction. Types of skin traction are described in Box 77-2. Figures 77-4 illustrates some types of skin traction.
IN PRACTICE: NURSING CARE GUIDELINES 77-2
PERFORMING CAST CARE
Synthetic Cast
• Check for rough edges. Petal as necessary. Pull sock or nylon stocking over the cast to prevent it from snagging on clothing. Rationale: It is important to protect the skin from any form of irritation.
• Do not immerse the cast totally in water However it is not necessary to prevent all contact with water Rationale: Although the cast is not likely to dissolve, when the cast or padding is soaked, the padding may begin to rot. Also, the underlying skin can itch or necrose.
• Keep in mind that the fiberglass cast is solid and does not give, as does a plaster cast. The fiberglass cast, as a result, may be too tight for comfort. Rationale: The tissues under casts can swell for as long as 3 days after injury. Any type of cast can become too tight, leading to damage to the nerves and blood vessels.
• Carefully wash, dry and gently massage the skin around the cast daily Rationale: A nursing priority is to monitor skin condition.
• Caution the person against being too active. Rationale: The cast can break, injuring the extremity further.
• Perform neurovascular checks frequently Rationale: Checks to monitor circulation, motion, and sensation are needed to identify problems early and to remedy the problem with the goal of preventing long-term complications.
Spica (Body) Cast
• Turn the client frequently Rationale: Frequent turning prevents development of pressure points, venostasis, and circulatory complications.
• Reassure the client when turning him or her Rationale: Turning may cause apprehension and fear of falling.
• Be sure no crumbs or other foreign substances get inside the cast. Rationale: Foreign material inside the cast can lead to itching and skin breakdown.
• Provide air conditioning, if possible. Hot weather is particularly uncomfortable for the client in a cast. Rationale: Perspiration under a cast causes itching and promotes skin breakdown.
• Give special attention to bladder and bowel elimination and to the area near the buttocks. Rationale: Cast breakdown because of moisture from urine or stool can result in skin breakdown and infections.
• Use a fracture bedpan for elimination. Remove these bedpans slowly Rationale: They overflow easily.
• Apply powder or lotion to the bedpan before placing it under the client. Rationale: This helps to slip the pan into place. Protect the bed with a waterproof pad.
• Report symptoms such as abdominal pain and a bloated feeling. The area of the cast over the stomach should be cut out. Rationale: Cutting out the area over the stomach helps to prevent superior mesenteric syndrome, also known as body cast syndrome. If the stomach area is not cut out, the stomach has no place for expansion after eating or if the person has gas. This could lead to partial or complete strangulation of the bowel.
• Encourage the client to exercise as much as possible. Isometric exercises should be done inside the cast. Rationale: Exercises encourage circulation and help prevent complications.
• Move the client out of the room on a stretcher or in a standing wheelchair Rationale: The cast could break, resulting in loss of immobility and further damage to the client.
• Encourage diversional activities. Rationale: Boredom and restlessness are common problems.
• Use several people or a hydraulic lift or chair to move the client. Rationale: Assistance is needed when moving the client to prevent injury to staff and the client.
• Encourage the client to do as much self-care as possible. Rationale: Participating in self-care helps to improve self-image and provides meaningful exercise.
IN PRACTICE: EDUCATING THE CLIENT 77-2
WEARING A CAST
• Follow the physician’s instructions regarding physical activity and limitations.
• Exercise the muscles. Move the fingers or toes frequently to reduce swelling, prevent joint stiffness, and maintain muscle strength. Do muscle-setting exercises (contracting and relaxing without movement) inside the cast to maintain muscle mass, tone, and strength.
• With a foot or leg cast, wear a cast walking shoe at all times, except when sleeping or showering.
• Elevate the cast extremity to prevent swelling.
• Avoid bumping the cast.
• Never stick anything inside the cast. It could result in itching, infection, or decreased circulation. (This consideration is especially important for children.)
• Never trim or cut back the cast.
• Keep a plaster cast dry If a synthetic cast becomes wet, pat it dry with a towel and dry it with a hair dryer using the low setting.
• When resting the cast on furniture, protect the furniture with a pad.
• Contact your physician if any of the following problems develop: unrelenting itching; foul odor from cast; drainage present through or around cast; pain unrelieved by medication; cast that feels very tight or too loose; cast that breaks, cracks, or becomes dented; painful rubbing or pressure inside the cast, especially in one particular place; limb that constantly feels cold; fingers or toes that are numb or tingling; fingers or toes that are white, blue, or the color of which does not return when pressed.
FIGURE 77-4 · (A) Buck’s traction. (B) Bryant’s traction. (C) Cervical halter traction.
