Plasterof Paris forearm aplication

Application of Below Elbow POP Slab

•   This type of slab is often used where short term immobili­zation is required, and where swelling is anticipated.

•   It is very useful where pain relief is the main reason for immobilization. Perhaps most commonly used in the treatment of a Colles fracture. Slab should be held at the two ends and drawn slowly through the water. It can then be held vertically by one end and the water allowed to drain off (Fig. 23.3).

•   Finally, the slab is allowed to collapse into the palm of the hand and is gently compressed to remove surplus water.

•   It is then spread out on a flat surface and air bubbles are squeezed out with the palm of the hand.

•   It is an important point in plaster technique that the layers should be well bonded together without air bubbles and dry areas otherwise the strength of the plaster will be adversely affected. If required, the plaster slab can be stren­gthened by drowning the wet plaster up into longitudinal ridges, taking care to avoid irregularities on the inner surface.

•   Counter traction is neces­sary when manipulating a fracture. A plaster slab is prepared from a 15 cm wide plaster bandage.

•   The arm is measured from the tip of the olecranon to the knuckles and the slab is arranged to be 5 cm longer than this measure­ment.

•   If required, the slab can be slightly wider at the elbow.

•   The slab is applied over a layer of well-fitting stockinet of over a single layer of plaster wool applied as a bandage.

•   Use a simple sling for this purpose.

•   A traction band is passed around the upper arm over a pad of wool and is fixed to a wall hook or other immovable object.

•   The fingers are then grasped by an assistant and the arm and hand are left completely free to allow application of the plaster.

•   If a Colles fracture has been manipulated, the correct position for the wrist can readily be achieved by applying traction to the thumb with the latterin line with the forearm. This gives the necessary degree of ulnar alignment.

•   The slab is laid along the dorsum of the forearm, wrist and hand and is moulded carefully to the limb.

•   The slab is bandaged on with a wet gauze bandage, care being taken not to pull this tightly.

•   Finally, the ends of the slab are folded back obliquely to leave a neat finish and to avoid restricting elbow and finger movements.

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Plaster of paris variety of applications

Usage of POP Bandages

The POP bandage can be used:

•   As a simple splint (slab to hold fractured bone and adjoining joints) (Fig. 23.1). Slabs of plaster for the purpose of making splints can be made by folding a plaster bandage along its length to form seven to eight layers. The foldings can be done dry or wet, the advantage of the dry technique being that the resulting slab can be tested for size against the length of the resulting slab can be ready, prepared before the manipulative procedure is carried out. The slabs can be increased in width by slightly overlapping each layer on the one below.

•   As a complete plaster cast (encircling POP device) to hold reduction long term for healing), the type and extent of the cast depending on the immobilization required:

Lower limbs:

     a.  Below knee cast.

     b.  Above knee cylinder cast.

     c.  Above knee (long leg) cast.

     d.  Hip spica.

Upper limbs:

     a.  Below elbow cast.

     b.  Above elbow cast.

     c.  Colles cast.

     d.  Scaphoid cast.

     e.  Shoulder spica.

Spine

     a.  Half-leg.

     b.  Full-leg.

     c.  Forearm.

     As a general rule, for adequate immobilization, the joint above and the joint below a fracture need to be incorporated in the plaster, although occasionally, if the fracture is very close to one end of a long bone, this rule may be broken.

     A plaster cast which is designed to immobilize the hip or shoulder is often known as a ‘spica’ (F also designed to immobilized the spinal cord as a plaster spinal jacket cast .

     Plaster of Paris is the most effective substance used in the immobilization of the trunk and limbs.

            The POP bandages are available commercially prepared, they are quick setting and extremely useful for maintaining reduction of fracture fragments. However, these bandages can also be prepared at the clinic to cut down the costs.

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Plaster of paris making of bandages

Preparing Handmade Plaster Bandages

Aim

To prepare plaster of Paris bandages by hand.

Procedure

   1.  To make handmade plaster bandages, starched cotton bandages of three, four and six inches which are prepared specially for this purpose are taken. They are available in various surgical stores.

   2.  The ideal mesh size of these bandages for holding the plaster should have 28 to 32 threads to an inch.

   3.  The usual length of the bandages is three yards, four yards and five yards for widths of three, four and six inches size respectively.

   4.  Regular dental grade of plaster of Paris powder, which should be free of grit used. If lumpy, the plaster must be sieved before it is used.

   5.  To make the plaster bandage, the powder is rubbed thoroughly into the mesh of bandage, the first portion of bandage being rolled so loosely as to leave a half-inch space in the center. If this detail is neglected, the inside part will not become wet when the bandage is immersed in water. If the powder is not rubbed uniformly into the bandage, there will be dry spots in the bandage as it is applied.

   6.  As the bandage is rolled no more powder should be added then it is held by the mesh, and it must not be rolled tightly. If either of these mistakes is made, the bandage will remain dry after it has been placed in water, and as a result the plaster will crumble when it is applied.

   7.  If, however, bandage is rolled too loosely, it is difficult to prevent it from “telescoping” it may be wrapped in waxed paper or a paper-napkin, or a rubber band is used to prevent it from unrolling.

   8.  Plaster bandages should be handled carefully to avoid shaking the powder out of the mesh.

   9.  It is important to store them in a dry place as dampness ruins them.

            10.       A liberal supply of plaster bandages of various widths should be available in the hospital at all times as they cannot be made on short notice.

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Plaster of Paris technique introducton

 Plaster of Paris (POP) Technique

INTRODUCTION

Plaster of Paris (POP) is made from gypsum (hemi hydrated calcium sulfate powder)and it is the practice for hospitals to make their own plaster bandages by impregnating wide mesh gauze bandages with dry plaster base. These are then carefully rolled by hand and used before they get decay storage.

     If the patient can afford the cost all plaster casts are now made from commercially produced bandages which are supplied in varying widths and are uniform in their spreading and setting characteristics.

•   POP bandages are reasonably cheap, versatile, widely available and easy to use, they are comfortable and, being somewhat porous, absorbs perspiration and secretions.

•   The strength of casts is adequate for most purposes and it is radiotranslucent.

•   It does also have disadvantages and many new materials are currently being developed as possible substitutes (Resins and Fiberglass).

•           Even when carefully built up to give maximum strength for weight and rigidity, there can be uncertain immobilization, particularly when POP is applied to a swollen limb. Finally, it is not waterproof and, for this reason, quickly disintegrates if allowed to get wet.

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Imaging Percutaneous Transhepatic Biliary drainage

Percutaneous Transhepatic Biliary Drainage

Objective

•   Drainage of obstructed biliary systems in cases of surgical obstructive jaundice

•   To treat cholangitis

•   Gain access to biliary tract for stone removal, stricture dilatation, stent placement.

Patient Preprocedure Preparation

•   Blood prothrombin time

•   Antibiotic cover 24 hours prior to procedure

•   Fasting for 6 hours

•   IV fluids and serum electrolytes baseline values

•   Surgical cleaning and draping of abdomen and right flank.

Position

Supine.

Anesthesia

•   IV sedation with diazepam

•   Local infiltration analgesia with 10 ml of 1% xylocaine

•   General anesthesia may be required in uncooperative patients.

Instruments

•   22 G, 20 cm long Chiba needle with stilet.

•   18 G, 20 cm long PVC sheathed needle with stilet.

•   0.035" or 0.038" diameter, 100 cm long J-shaped guidewire.

•   0.038" heavy duty straight guidewire.

•   Sterile surgical blades.

•   Graded teflon dilators 7F-10F.

•   Ring biliary drainage catheter 10F pigtail with multiple side holes extending about 10 cm above the pigtail.

•   Suture and needle for fixation of catheter.

•   Adhesive tape.

•   Connector.

•   3-way stopcock.

•   Collection bag.

•   Water soluble iodinated contrast 50-100 ml.

•   Syringes 20 ml, 10 ml.

•   Normal saline.

Procedure

   1.  Fluoroscopic guidance.

   2.  Patient positioned supine, right side toward operator.

   3.  Puncture site is in midaxillary line, choose intercostal space below maximum excursion of diaphragm.

   4.  Local analgesia infiltration.

   5.  Puncture intercostal space with 22 G neelde under fluoro­scopic guidance; direct needle toward Xiphisternum till the midline; remove stilet.

   6.  Perform cholangiography by injecting diluted (1:1) contrast while continuously withdrawing the needle.

   7.  As soon as bile ducts are opacified; stop withdrawing needle and inject more contrast till the entire biliary tree is opacified.

   8.  If no bileduct is opacified in the first attempt, repeat the procedure as above.

   9.  Once the biliary tract is opacified, under continuous fluoroscopic monitoring insert the 18 G sheathed needle through the same intercostal space to puncture a peripheral right lobe bile duct preferably a posterior branch.

10.  Withdraw stilette of needle-sheath assembly.

11.  Position of needle tip within a duct is confirmed by injecting few ml of contrast.

12.  Make a stab incision along needle.

13.  Remove cannula leaving the sheath in place.

14.  Insert guidewire through sheath into the biliary tract.

15.  Manipulate the guidewire into desired position if possible.

16.  Dilate tract over guidewire to 10F size.

17.  Insert biliary drainage catheter.

18.  Position catheter so that all sideholes are within the biliary tract/hepatic parenchyma.

19.  Remove guidewire.

20.  Connect catheter to collection bag.

21.  Suture catheter and skin wound.

22.  Secure catheter to skin wound.

23.  Secure catheter to skin with adhesive tape.

Complications

•   Bleeding

•   Biliary peritonitis

•   Cholangitis and septicemia

•   Electrolyte imbalance

•   Pneumothorax.

            *Alternatively, sonographic guidance can be used for perform­ing PTBD. This is specially indicated if the left sided ducts need to be drained. Puncture is made directly with the 18 G sheathed needle through the epigastrium. The remaining steps (10-22) are same as in the fluoroscopic guided technique.

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