- Email: [email protected]
A safer and more reliable technique for cast wedging
Injury Extra (2006) 37, 316—317
www.elsevier.com/locate/inext
CASE REPORT
A safer and more reliable technique for cast wedging J. Mutimer *, A Souter Department of Orthopaedics, Frenchay Hospital, Bristol BS10 1LE, UK Accepted 27 February 2006
Introduction Non-operative techniques for the management of closed tibial fractures are well accepted and proven to be very successful. Cast wedging itself is somewhat of a dying art with a move towards operative intervention in many cases traditionally managed successfully by cast immobilisation.1 Much debate has ensued as to the best method of calculating the size of the wedge required.2,7,8 Further discussion on the merits of the opening wedge,3 closing wedge5 and the opening-closing wedge4 have all tried to refine the technique including the precise positioning of the wedge. None of these papers have discussed the materials used for providing the wedge itself. Traditionally a piece of cork has been used6 with varying size pieces inserted into the gap created. There are two problems with this: (1) Cork is deformable and an accurate size wedge is difficult to cut. Under pressure it will also compress further and can disintegrate. (2) The cork can press against the skin as it is pushed in to position and anecdotally this has been known to cause skin necrosis on the tissue being compressed. * Correspondence to: 8 The Parade, Chipping Sodbury, Bristol BS37 6AT, UK. Tel.: +44 1454 316330. E-mail address: [email protected] (J. Mutimer).
Due to these problems a new wedge has been designed to overcome these problems.
Method Initially the size of wedge required is measured off the radiographs using the technique described by Gregson and Thomas.6 The magnification of the image can be taken into account as necessary. A suitable size wedge can then be chosen. These wedges are pre made in the medical engineering department from 2 layers of plywood bonded together (Figs. 1 and 2). This consists of a narrow strip being the width of the wedge required and a wider strip acting to prevent the wedge from pressing against the skin. Several widths of wedge are manufactured in 5 mm increments to allow for the size of wedge required. Following insertion of the wooden wedge (Fig. 3) a layer of plaster can be applied over the top to hold it in place (Fig. 4).
Discussion This is an accurate and reproducible method to wedge casts and aid non-operative treatment of tibial fractures thereby potentially avoiding an
1572-3461/$ — see front matter # 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2006.02.049
A safer and more reliable technique for cast wedging
Figure 1 Three prepared cast wedges made of plywood with 10, 15 and 20 mm spacers.
Figure 2
Cast wedge in profile view.
317
Figure 4
Spacer held in place by lightweight plaster.
anaesthetic for manipulation or operative intervention. Wedging probably does not have to be calculated exactly since due to the soft tissues around the fracture it will angulate slightly less than the angle to which the plaster is opened. However, correct assessment and the correct wedge size choice will reduce the need for more than one attempt at correcting the angulation. This technique allows for a safe method reducing any risk to the underlying soft tissues and is easy to learn and implement. This technique has been used successfully in our hospital with no complications. It is a reliable and safe technique to help manage tibial fractures conservatively. There are no conflicting interests in the preparation of this paper.
References
Figure 3 A spacer in place prior to covering in lightweight plaster.
1. Apley AG, Rowley DI. Editorial: fixation is fun. J Bone Joint Surg (Br) 1992;74-B:485—6. 2. Bebbington A, Lewis P, Savage R. Cast wedging for orthopaedic surgeons. Injury 2005 Jan;36(1):71—2. 3. Bohler L. The treatment of fractures, 5th ed, New York: Grune and Stratton; 1958. p. 1725, 1732, 1733. 4. Brown PW, Urban JG. Early weightbearing treatment of open fractures of the tibia. J Bone Joint Surg 1969;51A:59. 5. Charnley J. The closed treatment of common fractures, 4th ed, Cambridge: Colt Books; 1999. p. 231. 6. Gregson PA, Thomas PBM. Tibial cast wedging: a simple and effective technique. J Bone Joint Surg 1994;76-B: 496—7. 7. Schulak DJ, Duyar A, Schlicke LH, Gradisar IA. A theoretical analysis of cast wedging with practical applications. Clin Orthop 1978;130:241—4. 8. Thomas FB. Precise plaster wedging: fracture-angle/cast diameter ratio. BMJ 1965;921.
www.elsevier.com/locate/inext
CASE REPORT
A safer and more reliable technique for cast wedging J. Mutimer *, A Souter Department of Orthopaedics, Frenchay Hospital, Bristol BS10 1LE, UK Accepted 27 February 2006
Introduction Non-operative techniques for the management of closed tibial fractures are well accepted and proven to be very successful. Cast wedging itself is somewhat of a dying art with a move towards operative intervention in many cases traditionally managed successfully by cast immobilisation.1 Much debate has ensued as to the best method of calculating the size of the wedge required.2,7,8 Further discussion on the merits of the opening wedge,3 closing wedge5 and the opening-closing wedge4 have all tried to refine the technique including the precise positioning of the wedge. None of these papers have discussed the materials used for providing the wedge itself. Traditionally a piece of cork has been used6 with varying size pieces inserted into the gap created. There are two problems with this: (1) Cork is deformable and an accurate size wedge is difficult to cut. Under pressure it will also compress further and can disintegrate. (2) The cork can press against the skin as it is pushed in to position and anecdotally this has been known to cause skin necrosis on the tissue being compressed. * Correspondence to: 8 The Parade, Chipping Sodbury, Bristol BS37 6AT, UK. Tel.: +44 1454 316330. E-mail address: [email protected] (J. Mutimer).
Due to these problems a new wedge has been designed to overcome these problems.
Method Initially the size of wedge required is measured off the radiographs using the technique described by Gregson and Thomas.6 The magnification of the image can be taken into account as necessary. A suitable size wedge can then be chosen. These wedges are pre made in the medical engineering department from 2 layers of plywood bonded together (Figs. 1 and 2). This consists of a narrow strip being the width of the wedge required and a wider strip acting to prevent the wedge from pressing against the skin. Several widths of wedge are manufactured in 5 mm increments to allow for the size of wedge required. Following insertion of the wooden wedge (Fig. 3) a layer of plaster can be applied over the top to hold it in place (Fig. 4).
Discussion This is an accurate and reproducible method to wedge casts and aid non-operative treatment of tibial fractures thereby potentially avoiding an
1572-3461/$ — see front matter # 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2006.02.049
A safer and more reliable technique for cast wedging
Figure 1 Three prepared cast wedges made of plywood with 10, 15 and 20 mm spacers.
Figure 2
Cast wedge in profile view.
317
Figure 4
Spacer held in place by lightweight plaster.
anaesthetic for manipulation or operative intervention. Wedging probably does not have to be calculated exactly since due to the soft tissues around the fracture it will angulate slightly less than the angle to which the plaster is opened. However, correct assessment and the correct wedge size choice will reduce the need for more than one attempt at correcting the angulation. This technique allows for a safe method reducing any risk to the underlying soft tissues and is easy to learn and implement. This technique has been used successfully in our hospital with no complications. It is a reliable and safe technique to help manage tibial fractures conservatively. There are no conflicting interests in the preparation of this paper.
References
Figure 3 A spacer in place prior to covering in lightweight plaster.
1. Apley AG, Rowley DI. Editorial: fixation is fun. J Bone Joint Surg (Br) 1992;74-B:485—6. 2. Bebbington A, Lewis P, Savage R. Cast wedging for orthopaedic surgeons. Injury 2005 Jan;36(1):71—2. 3. Bohler L. The treatment of fractures, 5th ed, New York: Grune and Stratton; 1958. p. 1725, 1732, 1733. 4. Brown PW, Urban JG. Early weightbearing treatment of open fractures of the tibia. J Bone Joint Surg 1969;51A:59. 5. Charnley J. The closed treatment of common fractures, 4th ed, Cambridge: Colt Books; 1999. p. 231. 6. Gregson PA, Thomas PBM. Tibial cast wedging: a simple and effective technique. J Bone Joint Surg 1994;76-B: 496—7. 7. Schulak DJ, Duyar A, Schlicke LH, Gradisar IA. A theoretical analysis of cast wedging with practical applications. Clin Orthop 1978;130:241—4. 8. Thomas FB. Precise plaster wedging: fracture-angle/cast diameter ratio. BMJ 1965;921.