NCM 116

MEDICAL SURGICAL NURSING

R L E / PROF. MARCELO
______________________________________________________________________________________________________________
PRELIMS
→ Perform interventions to control the swelling of the area.
WEEK 1 - DAY 1 → Common areas of swelling shoulder, knee
I. General Musculoskeletal Assessment → RICE (Rest, Ice, Compression, Elevate) - simplest interventions
II. Generalized Screening Exam you can perform to control swelling
A. Neck: Active Range of Motion → Apply elastic bandage
B. Special Tests for the Neck → If the px is in pain (with no protrusions), there is a possibility the
C. Shoulder Exam px is suffering from a specific fracture.
D. The Elbow ● Deformities
E. Special Tests for the Elbow → Immobilize the px
F. Wrist and Hand ● Atrophy
G. Anatomy of the Elbow ● Erythema
H. Nerves of the Hand
I. Special Tests of Hand and Wrist B. RANGE OF MOTION (ACTIVE)
III. Diagnostic Assessment ● Have patient range the joints
A. Electromyography ● Watch for decreased or increased movement of the joint compared
B. Arthroscopy to the other side as well as the norm
C. Other Tests ● Watch for pain with movement
D. Video Assessment → Review the quality and severity of the pain before and after the
intervention
I. GENERAL MUSCULOSKELETAL ASSESSMENT → Assess pain using pain assessment (PQRST) and pain scale
GENERAL APPROACH → Pain should subside before proceeding to the procedure
● History ● Listen for crepitus or “popping”
→ Perform a thorough history taking every shift. → Usually not normal (only in elderly px with arthritis)
● Inspection → Common to patients with fracture (may be a result of loss of
→ Part of assessment synovial fluid)
→ Inspect for intact screws/hardwares attached to the patient. ● Watch for abnormal movements
→ Meticulous skin care (not limited to wound dressing) → 1st manifestation
→ Loss of sensation, unrelieved pain, necrosis – common → Frozen movement when asked to raise hands/arms may indicate
problems to look out for fracture
● Range of Motion (ROM) → Document if px cannot tolerate specific movement
→ Active and Passive ROM exercises (e.g. supination and
pronation) C. RANGE OF MOTION (PASSIVE)
→ Check doctor’s order what type of ROM exercise is needed ● Next range the joints passively, comparing the end joints to the
by the px active
→ Tractions and affected muscles should not be easily → Review the chart of the patient thoroughly before interacting with
maneuvered. the patient (to know the contraindications)
→ Check for presence of pain while doing exercises ● Again note any decreased or increased movement
(sometimes given pain meds prior) ● Pain with movement
● Palpation → Do not talk with a patient if you have no background about the
→ Assess the skin integrity and blood circulation of the client. px.
→ Any presence of swelling, tenderness, pus are signs of → Be careful when interacting with the client, especially with
impending infection and must be reported. tractions/sandbags, etc.
● Muscular and Neurological Exams ● Crepitus or “popping”
→ Difference and symmetry should be considered → Read the px’s kardex
→ Pain, gait, sensory, and motor responses
→ Alterations in muscle control of stroke patients (shortening, D. PALPATION
weakness in parts of the body) despite recovery
● When palpating a structure, you need to know the anatomy of that
structure
A. GENERAL INSPECTION → Know where the tractions are usually attached
● Observe how the patient moves as they go into the room or move ● Palpate for swelling
from chair to table ● Palpate for warmth
→ If px is in pain, stop the assessment ● Palpate each area of the structure in turn evaluating for pain and
● General Appearance abnormalities as compared to the other side
→ Head to Toe → Review of basic anatomy
→ Injuries/Fracture are usually from accidents
→ Px is ambulatory while having a stroke: depends on the pain E. MUSCULAR AND NEUROLOGICAL
tolerance and pain threshold
● Body proportions ● Check the following comparing one side to the other:
→ It is important that the nurse is familiar with the normal anatomy → Grade strength (0-5)
and physiology of the musculoskeletal system. → Grade reflexes (0-4) 
→ Sensory exam
Inspection of Specific Area
● Look for asymmetry between sides II. GENERALIZED SCREENING EXAM
→ You should know the normal anatomy and physiology of the ● If there are any abnormalities, a more thorough exam of the joint
musculoskeletal system to easily recognize any deviations and needs to be done.
perform appropriate interventions. ● Each joint is:
● Swelling → Inspected (look for abnormalities)

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 → Palpated
→ Examined

A. NECK: ACTIVE RANGE OF MOTION

● Chin to chest (flexion)
● "Look at ceiling" (extension)
● Chin to each shoulder (lateral rotation)
● Ear to each shoulder (lateral flexion, i.e., head tilt)

The Shoulder
● Joins of the shoulder
→ Glenohumeral
→ Sternoclavicular.
→ Acromioclavicular
→ Scapular throcaic (not a true joint)

Scapulothoracic
● Scapular stabilizing muscles:
→ Trapezius (all three portions)
→ Serratus anterior
→ Rhomboids
→ Levator scapulae
→ Pectoralis Minor
→ Ambulation is key to fast recovery. If the patient cannot tolerate
ambulation, assist with simple turning and encourage simple
exercises.

B. SPECIAL TESTS FOR THE NECK

Dekleyn Test
● Head and neck rotation with extension.
● Tests for vertebral artery compression.

Spurlin’s (Foraminal Compression) Test Sternoclavicular Joint

● Patient extends and rotates head to side, the examiner then applies ● These structures still allow for 35 degrees of elevation, 35 degrees
axial load to the head. Positive test is when there is pain radiating of translation, and 50 degrees of rotation at the sternoclavicular
into the arm. joint.
● Indicates Pressure on a nerve root.

Elvey Test
● Upper limb tension tests: tests designed to put stress on the
neurological structures of the upper limb.
A. Median nerve C5,6,7
B. Median nerve, axillary nerve
C. Radial nerve
D. Ulnar nerve C8, T1
Shoulder
C. SHOULDER EXAM ● Have patient place each hand:
● Inspection 1. Behind head (external rotation and abduction)
● Palpation 2. Up the small of the back (internal rotation)
● Passive Range of Motion
● Palpation of the shoulder includes:
● Active Range of Motion → Sternoclavicular joint
→ Apley scratch test for internal/external rotation → Acromioclavicular joint
● Impingement Signs → Subacromial area
→ Assess pain using pain assessments and scorings (may → Bicipital groove
differ between adult and children patients) → Muscles of the Scapula
→ Pain is subjective
● Bicep Tendonitis/Crossarm adduction/apprehension
● Neck exam: compression test
● Adson's maneuver
→ Check the radial pulse while arm is stretched towards the
back and let the patient move their head from side to side

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 G. ANATOMY OF THE ELBOW

D. THE ELBOW
H. NERVES OF THE HAND
● Palpation: lateral and medial epicondyles, olecranon, radial
● Ulnar
head, groove on either side of the olecranon
● Radial
→ Always check the sensation by assessing the fingers since
● Median
the elbow will be covered by cast.
● Palmar branch of the median
→ Are patients allowed to take a bath when they have a cast?
Yes, but the affected area should be stabilized, UNLESS
contraindicated.
→ bed bath is done to those px who are bedridden
● Inspect the carrying angle, and any nodules or swelling
● Check px capacity to move or ambulate

I. SPECIAL TESTS OF HAND AND WRIST

Cascade Sign
● Patient flexes the fingers, the tips should all converge toward the
scaphoid tubercle. If they do not, it may indicate a fracture in that
E. SPECIAL TESTS FOR THE ELBOW finger.

Varus Test Boutonniere Deformity

● Tests for ligamentous stability of the lateral collateral ligament
Valgus Test
● Tests the medial collateral ligament
Cozen’s Test (Lateral Epicondylitis / Tennis elbow test)
● Patient makes fist and pronates the forearm radially deviates
and extends the wrist against resistance. Positive if pain in the
lateral epicondyle area.
Golfer’s Elbow Test
● While palpating the medial epicondyle, the forearm is supinated
and the elbow and wrist are extended. Positive if pain over the
medial epicondyle.
● Extension of the MCP and DIP joints and flexion of the PIP joint.
This is due to a rupture of the central tendinous slip of the
extensor hood.
Swan-neck Deformity
● Flexion of the MCP and DIP joints, with extension of the PIP
joint. This is due to contracture of the intrinsic muscles. Seen
after trauma or in RA.
→ Board exam question: Boutonniere and Swan-neck deformity
are signs of arthritis
Ulnar Drift
● Ulnar deviation of the digits most commonly due to RA.

Tinel’s of the Elbow Dupuytren's contracture

● Percussion of the ulnar nerve in the grove. Positive if radiating ● This is due to contracture of the palmar fascia. Most common in
sensation down arm into hand. the ring finger or little finger, men more than women, ages 50-70.

F. WRIST AND HAND Claw fingers

● Inspect for swelling or deformities
● Palpate: anatomic snuff box, volar and dorsal aspects of the
wrist, all joints of the fingers
● Flexion, extension, ulnar and radial deviation of the wrist
● Have the patient make a fist and extend and spread the fingers.
→ Arthritis: common to elderly female px
● This deformity is a form of a combination of an ulnar and median
nerve palsy. This causes loss of intrinsic muscle function and
over action of the extrinsic extensors. This causes
hyperextension of the MCP joints and flexion of the PIP and DIP
joints. If the intrinsic function of the hand is lost, it is then called
an intrinsic minus hand.

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Thumb ulnar collateral ligament test C. OTHER TESTS
● Test for gamekeeper's or skier's thumb ●  one scan
B
● Valgus stress applied to the MCP joint, if 10-20 degrees there is ● Magnetic resonance imaging
most likely a partial tear → Remove metal parts before procedure
● Ultrasonography
Carpal Compression Test
● Pressure applied directly to the carpal tunnel for 30 seconds. If
positive, indicates carpal tunnel syndrome. D. VIDEO ASSESSMENT
● https://www.youtube.com/watch?v=aUMTPa_9qlY
Froment’s Sign ● History Taking
● Patient holds piece of paper between the thumb and index ● Head-to-Toe Assessment
paper. If the distal phalanx flexes, it is a positive test and → Start with the tempomandibular joint (TMJ), inspecting each
indicates ulnar nerve palsy. If the MCP joint hyperextends, it is a joint for any abnormalities like swelling, crepitus,
positive leanne's sign and also indicates ulnar nerve palsy. increased/decreased in movement.
→ Palpating the spinal processes in the neck all the way
Allen Test down.
● Tests for competency of the ulnar and radial arteries. → Inspecting the ROM of the neck.
→ Proceed to shoulder assessment (lift hands up the head,
Anatomic Snuffbox swing hands, relax, lift shoulder, palpate for any pain on the
● Lies between the extensor pollicis longus and extensor pollicis shoulders)
brevis tendons. The scaphoid bone is palpated inside the box as → Palpate and bend the elbows
well as the radial styloid. Pain in the box should indicate → Check the strength of the elbows.
scaphoid fracture until proven otherwise. → Bend the wrists up and down.
→ Spread the fingers apart, then put them together. Bend the
III. DIAGNOSTIC ASSESSMENT fingers up and down. Check the strength of fingers.
●  aboratory tests serum calcium and phosphorus, alkaline
L → Palpate joints (no tenderness, no difficulty w wrist or finger)
phosphatase, serum muscle enzymes → Proceed to hips
→ needs NPO → Px lies down
● Radiographic examinations standard radiography, bone density, → Palpate hips (no pain present)
tomography and xeroradiography, myelography, arthrography, → Move the right leg as far as the patient can, lift it up and
and; down, bend the knee, put it inward then outward. Repeat
● Other diagnostic tests: bone and muscle biopsy with the left leg.
→ Suspecting for tb cancer, bone cancer → Palpate both feet, ankles and toes, checking every small
bones.
A. ELECTROMYOGRAPHY → Palpate all the spinous processes all the way down the
●  MG aids in the diagnosis of neuromuscular, lower motor
E back.
neuron, and peripheral nerve disorders; usually with nerve → Look for the symmetry of the shoulders and scapula.
conduction studies. → Look at the spine from the side.
● Low electrical currents are passed through flat electrodes placed → Check the range of motion of the spine.
along the nerve. ● Wear gloves when assessing the patient.
● If needles are used, inspect needle sites for hematoma ● After assessment, there is a proper tool for documentation to
formation. note for any abnormalities.
● Golden rule: Only write what you observe during the assesment
B. ARTHROSCOPY (documentation).
●  iber Optic tube is inserted into a joint for direct visualization.
F
● Patient must be able to flex the knee; exercises are prescribed
for ROM.
● Evaluate the neurovascular status of the affected limb frequently.
● Analgesics are prescribed.
● Monitor for complications.
● Need consent : INVASIVE PROCEDURE

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 ● There should be no friction
WEEK 1 - DAY 2 → You have to check the pulley if there is any friction or if the
IV. Orthopedic Gadgets and Hardware ropes are entangled
V. Learning Objectives ● The line of pull must be in line with the deformity
VI. Traction → Check the pulley, it should be in line with the deformity.
VII. Different Types of Traction
→ The 1st pulley should be in line with the inguinal area of the
VIII. Casts
IX. Braces patient.
X. Hardware → The 2nd pulley should be in line with the knee of the
XI. Fixation patient.
XII. Spinal Instrumentation → The 3rd pulley should be in line with the first and second
XIII. Prosthesis pulley.

How to Prevent Friction

IV. ORTHOPEDIC GADGETS AND HARDWARE ● There should be no knots near the pulley
● Gadgets include tractions, braces, and casts. → If there are knots near the pulley it will not be effective
● Hardware includes nails, intramedullary nails ● Weights should be hanging freely
→ Made of titanium, expensive. ● Cords should be running along the groove of the pulley
→ Check the height of the bed, the pulley should be in the
V. LEARNING OBJECTIVES center of its groove.
● Learn the different orthopedic hardware and gadgets. ● Observe for the wear and tear of the ropes and the bags
● Identify the different functions of each orthopedic hardware and
→ A bag is placed above the px’s bed, if the sandbag falls it
gadgets.
● Discuss nursing management for the patient with casts, braces, will lead to further fracture.
and tractions. → The bags are usually 10% of the weight of the px
● Identify the parts of the bones that are usually applied with → Steinmann pins are used for skeletal traction of femoral
different hardware and gadgets.AN fractures.

VI. TRACTION
● An act of pulling and drawing associated with counter traction
→ Main responsibility of the nurse is to determine if there is a
counter traction
→ At least 23-24 hours a day, there should be a counter
traction
→ It should be continuous
→ Challenge is px is usually in pain

A. PURPOSE OF TRACTION
● For immobilization
→ We need to immobilize once nakatraction
● To correct & prevent deformity
→ Patients with fractures have problems with the bone
connection.
→ If the px has a fracture, we need to correct and wait for
callus formation
● To prevent or lessen muscle spasm and pain
→ Fractures are very painful.
→ To prevent that, we need to apply traction.
● Prevent further fracture
→ If the bone is not aligned and is used, it will lead to further
fracture and may lead to deformity
● To maintain good body alignment
→ For the px, to return - we need to apply traction
● For support
→ Bones need to be supported while waiting for the callus
formation
B. PRINCIPLES OF TRACTION
● The patient must be in a supine or dorsal recumbent position
● The traction must be continuous
→ Pulley should only be raised for 30 minutes to 1 hour while
the patient is taking a bath
→ if traction is not continuous the deformity will not be
corrected (not effective)
→ Pediatric patients are usually uncomfortable with pulley
● There must be a counter traction
→ Pulley must be hanged
C. PREPARATION
Check the doctor’s order
● Patient’s name
● Extremity to be placed on BST
● Weights to be applied
→ (should be 10 percent of the px body weight)
→ e.g. 50 kilos BW. 10% is 5 kilos
Prepare patient psychologically
● Introduce yourself to patient
● Inform patient on what is to be done
→ Check educational attainment of the px to determine
whether to explain the procedure in Filipino or English.
● The purpose of the treatment
→ Emphasize why there is a continuous traction
● Expectations of the patient to nurse
→ The patient expects the nurse to clean the insertion site or
pin tract (done 3x a day: morning, afternoon, night)
→ check of the activities of daily living (ex. oral care)
● Nurse's expectations from patient
→ The nurse expects cooperation from the patient.
→ Expect continuous traction
→ Expect to turn side to side or else px experiences
complications
→ Expect the px to hold the trapeze, sway, and take a deep
breath.

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Prepare the orthopedic bed

● Rest Splint - attached to the Thomas splint and Pearson’s

attachment.
. → If px needs to go to Xray, connect thomas splint and rest
Balkan Frame splint to ensure continuous traction.

● 4 Vertical Bars
● 4 Bars Rest Splint
● 1 diagonal bar
● Shock (color red) ● Braun bohler splint
● Fracture Board → Patient’s feet is inserted

Braun Bohler Splint Clips or Pins

Fracture Board Firm Mattress

Slings
● 3 sash cords:
Clamps Overhead Trapeze Pulleys → Thigh rope
→ Traction rope
● Overhead trapeze is attached to the diagonal bar → Suspension rope
● Check for 3 pulleys → The length of sash cords depend on the weight of the px’s
femur.

● Foot pedal or foot board

● Thomas Splint (with half ring) and Pearson’s Attachment

→ Only attach Pearson’s attachment once the femur is
measured.

● 2 weight bags:
● Steinmann’s Pin Holder → Traction weight (10% of pt’s. body weight)
→ Suspension weight (½ o traction weight)

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 → Some patients are dependent on nurses/caregivers for
turning.
→ It’s up to the nurse to encourage patients who can move to
turn side-to-side to prevent bedsores.
● Urinary and Bladder Problem
→ if the px is not moving, there is no abdominal peristalsis
→ Px does not feel the urge to pee, urine retains
→ Px is dependent to the nurse
D. PRINCIPLE IN APPLICATION OF SLINGS
● Bowel Elimination
● Start application from the medial aspect of the Thomas splint &
● Infection
fasten at the lateral aspect with clips or pins (to prevent injury).
→ If it's not cleaned 2x a day it may lead to osteomyelitis
→ 2 long slings are applied near the thigh (medial aspect)
● Deformity
→ Make sure the clips and pins are covered and do not touch
→ If the patient does not have callus formation or if they raise
the skin
their balance skeletal traction, the bones will have
● Apply slings snugly, not too tight (so as not to impede circulation)
deformities for life.
nor too loose (which defeats the purpose of support).
→ If too tight, if you place the foot the slings will be removed.
G. NURSING CARE OF PATIENTS IN TRACTION
→ too loose, foot may slip
● The smooth surface of the slings should come in with the
patient's skin (to prevent skin irritation). Hygiene and Comfort
→ Patients stay for 3-4 months. If the slings are not smooth, ● Hair shampoo
the patient’s skin will be dry, resulting in wounds. ● Bed bath
● Provide approximately an inch space between slings ● Perineal care
● (for ventilation) → Assist the px
● If slings are too long, fanfold it ● Oral care
● Number of slings will vary with size of patient's leg ● Ear care
● Keep the ankle and the popliteal area free from slings ● Nail care
→ These are highly vascular areas which may impede the → Especially for pedia px
circulation
● The broader and longer slings are for the thigh area while the Prevent Infection
● Observe insertion site
narrower and shorter ones are for the leg area
→ Redness
→ Discharge
E. THE KNOTS
→ Necrotic tissue
● Slip Knot – when the rope is slipped, it will tighten. → Foul Smell
→ Right over left → Fever (do not wait for this sign to manifest)
→ Ipapasok ● Proper cleaning of site
→ Yung right ipapasok ulit → Should be in outward, circular motion
→ Hawakan sa taas and slip → One cotton balls soaked in betadine then dispose
● Proper handwashing
→ To avoid infection on the insertion site and
hospital-acquired pneumonia

Proper Nutrition
● Calcium – bones (for faster healing)
● Protein – tissue repair (ex. eggs, chicken, meat)
● Clove Hitch Knot ● Roughage – elimination (high fiber diet e.g. whole grains, green,
→ Consume all the rope. If the rope is hanging, it might come leafy vegetables)
in contact with the patient’s skin and result in wounds. ● Vit. C – resistance and wound healing
● Vit. K
● Vit. D
● Iron

Prevent Pressure Sores

● Wrinkle-free linens
→ Linens should be kept dry, especially in government
● Ribbon Knot hospitals since the patient might not have an extra one.
→ Used on the foot board ● Keep skin dry
→ After bed bath, make sure to dry the patient thoroughly. If
the patient is moist, they might acquire pneumonia.
F. COMPLICATIONS OF TRACTION
● Massage bony prominences
● Pneumonia
→ Promotes circulation
→ Because the px is bedridden
● Swinging with the use of the overhead trapeze
→ Nurse does not watch hands (hospital acquired pneumonia)
→ Swing at least every 2 hours
● Bedsore
→ Since the patient is bedridden, there is poor circulation.
Exercise of Unaffected Extremity
● Done by PT students

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● Done 2x a day ● Inserted at the parietal area
→ ROM ● Usually seen in Pott’s disease affecting the spine.
→ Flexion and extension
→ Quadriceps setting exercise
● Prevent pulmonary problems
→ Deep breathing and coughing exercises
→ Back tapping
→ Increase fluid intake
■ Prevent pulmonary problems

Diversional Activities
● Puzzles
Balanced Skeletal Traction
● Newspapers or books ● Hip and femur affection
● Coloring books (for pedia patients) ● The 1st pulley should be in line with the inguinal area of the
● Toys, such as dolls, cars, etc. patient.
→ Make sure to check the age of the client to make sure that ● The 2nd pulley should be in line with the knee of the patient.
the toy is appropriate. ● The 3rd pulley should be in line with the first and second pulley.

Attend to Any Complaint of the Patient

● Referable complaints:
→ Severe pain
→ Check for possible signs of infection.
→ Difficulty sleeping
→ Problem with elimination

VII. DIFFERENT TYPES OF TRACTION

Overhead Traction
A. MANUAL TRACTION
● Affection of supracondyle of humerus
● Manual Traction - a pulling force applied by the hands of the
operator

B. SKELETAL TRACTION
● Skeletal Traction - the pulling force applied directly to the bone
using pins and wires such as Kirshner’s wire, Steinman’s pin,
Vinke’s skull retractor, and Crutchfield tongs.
→ Example: affection of the femur, cervical, spine, or hip
→ “Injury, fractures, affection” - all pertain to fractures

Kirschner’s Wire Holder Ninety-Ninety Degrees Traction

● Affection of the radius and ulna (upper extremities); thinner than ● Subtrochanteric and Proximal 3rd fracture of the femur
the Steinmann’s pin ● Mostly used in pedia patients

→ The bigger the bones, the bigger the intramedullary nail

used Halo-Pelvic Traction
● For C-type scoliosis
Steinmann’s Pin Holder → Single curvature
● Affection of the humerus, femur, tibia, fibula ● Attached to the pelvic

Crutchfield Tong
● Affection of upper dorsal cervical spine

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Halo-Femoral Traction
● For S-type scoliosis
→ 2 curvatures: lumbar and thoracic
→ 2 pulleys attached: head and feet

Dunlop Traction
● Adhesive Type
Bohler Braun Splint ● Supracondylar fracture of the humerus
● Fracture of proximal 3rd and Middle 3rd of tibia-fibula
● Supports the lower leg
● T(taba)ibia - F(payat)ibula

Zero Degree Traction

● Adhesive Type
C. SKIN TRACTION
● Neck of humerus and shoulder joint
● The application of a pulling force to the skin from where it is ● Weights present
transmitted to the muscles and then to the bones. ● Skin traction

Adhesive Type
● Materials used: Wooden spreader, Wadding sheet, Elastic
bandage, Adhesive tape..

Non-Adhesive
● Material used: Metal spreader, Slings, Canvas, Leather, foam,
straps with buckles and laces
● Not one size fits all; Patient is measured because it should fit the
client.

Bryant’s Traction
● Adhesive Type
● Congenital hip dislocation for children 0-3 years old
● Cannot be used for children more than 3 years old and obese
children due to heavier legs

Head Halter Traction

● Cervical spine affection
→ Slip disc
→ Pott’s disease affecting the cervical
Buck’s Extension Traction ● Bed is elevated on the head part
● Adhesive Type ● Head is higher than the foot
● Affection of hip & femur for children above 3 years old
● The pulley should not touch the floor.

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Pelvic Girdle Traction
● For Lumbo-Sacral Spine affection
● For HNP (Herniated Nucleus Pulposus)
● Bed is elevated on the foot part
● Very prominent to nurses due to frequent carrying of patients
Circo-Electric Bed
● To turn patient through vertical sequence
● In different countries like the U.S., this is usually used in patients
with fractures and burns. You cannot come in contact with the
patient, so the bed is turned instead.

Cotrel Traction
● Combination of Pelvic girdle and Head halter
● Severe Scoliosis
→ S-type Stryker Frame Bed
● Bed is not elevated ● To turn patient through horizontal sequence
● Px is in a supine position ● For patients with severe spinal injury. The bed is turned instead
the patient.

Hammock Suspension Traction VIII. CASTS

● For pelvis affection ● A temporary immobilizing device
● E.g. Malgaigne fracture (severe fracture of the pelvis - unstable
pelvis) Plaster of Paris
● Made of gypsum sulfate
● Drying takes 1-3 days
● Cheaper, Heavy
● Technicians usually don’t use gloves when applying this

Modified Buck’s Extension Traction

● For hip and femur affection

Fiber Glass
● Made of polyurethane
● Lightweight and dries in 20-30 minutes
● For pediatric clients, they may have designs.
● More expensive than the plaster of paris

Boot Cast Traction

● For post-poliomyelitis with residual paralysis
● Used to children with post poliomyelitis
● Not effective to older adult clients

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 A. MOLD
● Used for splinting the affected part of the body with an open
wound, inflammation, abrasion, swelling, or infection
● Cast is not applied in these cases because moist may promote
osteomyelitis
B. FUNCTIONS OF CAST
● To correct or prevent a deformity
● To support, maintain, and protect realigned bone
● For Immobilization
→ Without cast, the px will not be able to move due to pain
● To obtain a mold of a limb to serve as a model in making an
artificial limb
→ E.g. Px is amputated and needs prosthetic limbs, cast is
used
● To promote healing and early weight-bearing
→ If px has callus formation, he/she can gradually move the
area
→ Doctor orders Patellar Tendon Bearing (PTB) cast
C. PRINCIPLES IN THE APPLICATION OF CAST
● Apply the padding first before applying cast
→ Plaster of paris is not applied directly on the skin. Use of
stockinette.
● Apply cast by including the joint above and the joint below the
affection
→ Not only the site of fractures should have a cast, the area
above and below should also be included for support.
● Apply cast in circular motion and smoothen with the palm
→ Use the palm to smoothen the cast while it is drying to
avoid rough surfaces on the cast.
● Support with the palm
→ Below the fractured area
D. CONTRAINDICATION
● Pregnancy
→ They are prone to edema or swelling (3rd trimester).
→ Restrictive, so it will impede the circulation of the mother
and the baby.
● Skin Disease
→ Moisture can worsen the skin disease of the patient →
leads to further discomfort or infection
E. CAST SYNDROME
● Impaired Venous Circulation
→ Swelling
→ Pain / Discomfort
■ Let the client describe the discomfort
■ Assess for pain and discomfort,
→ Cyanosis of Nail Beds
■ Compare right and left nail beds
→ Muscle Spasm
■ immediately remove the cast and refer
■ Client complains of numbness
● Impaired Arterial Supply
→ Slow Capillary Refill
● Abdominal Pressure
● Feeling of Tightness or Bloating
→ Long leg circular cast
→ Check the tightness of the cast. If it is too tight, remove the
cast.
● Inability to Take Deep Breath
→ Immediately after applying the cast, ask the px to take a
deep breath.
→ Check O2 saturation
BSN-3C
F. PLASTER SORES
● Burning, itching, or stabbing pain
→ Referable
● Disturbed sleep
→ One crucial assessment with a fractured patient is sleep.
→ Document the hours of sleep.
● Elevated temperature
● Heat and swelling of the digits
→ Abnormal and should be referred
→ Compare both sides left and right
● Visible pus or staining of the cast
● All complaints of the patient should be taken seriously.
G. NERVE DAMAGE
● Deep pain in the feet and legs
● Loss of sensation in the legs and arms
→ Compare left and right side
● Muscle twitching, cramping, weakness
→ When there is muscle twitching when applying cast, refer.
● Feeling bloated/heartburn after eating only a little food
● Vomit food that has not been digested well
→ Describe the vomitus
● Problem with swallowing
→ Check for the tightness of the cast
● Either loose stools or hard stools.
→ Patient should defecate regularly (everyday)
→ we can advise the patient to eat papaya
→ constipation → common side effect of iron supplement
● Lightheadedness / Fainting on standing
● Sudden fatigue, sweating, shortness of breath, nausea, and
vomiting.
● Problems with erections; Women may have vaginal dryness or
orgasm problem
→ Included in the assessment
→ Elderly female px: vaginal dryness is NORMAL
● Either there is leaking urine or unable to empty bladder
● Too much sweating
→ Cold, clammy sweat or too much sweating is referable
H. MATERIALS NEEDED IN CAST APPLICATION
● Directly in contact with the skin
● Wadding sheet – serve as padding
● Plaster of Paris / Fiber Glass - casting material
→ Soaked in lukewarm water; do not use hot or cold water
→ When soaked in water, it will turn into a cement-like
material.
11
 I. EQUIPMENTS NEEDED IN THE APPLICATION OF
CAST
L. REINFORCEMENT
● Electric cast cutter – used in windowing, bivalving, and cast
● Reapplication of Plaster of Paris for the purpose of regaining its
removal
strength in case of the cast getting wet which resulted to its
instability
● Commonly used in pediatric patients born with talus
equinovarus.

● Trimming knife - smoothen the edges of cast

M. NEUROVASCULAR ASSESSMENT FOR PATIENT

WITH CAST
● Maggie Chewed Nuts Everywhere She Went
● Cast Spreader - to widen a bivalved cast → Movement
■ Do the two arms have similar movements?
→ Color
■ nail bed
→ Numbness
■ Use ballpen and ask patient what they feel
→ Edema
■ Check the grade of the edema if present.
→ Sensation
■ Check if the sensation is the same with right and left
→ Warmth
■ Sign of infection
● Bandage Scissor - to cut wadding sheet and stockinette
N. HOW TO APPLY A CAST
J. WINDOWING ● Measure stockinette and apply to cover the area and extend
● Putting a square / rectangular hole on the extremity with cast about 10 cm beyond each end of the intended splint site.
where there is an open wound for the purpose of visualization, → Generally, a stockinette 2 to 3 inches wide is used for the
inspection, dressing, as well as application of medication. upper extremities and 4 inches wide for the lower
extremities.
→ Cast technician applies the cast, the doctor only orders.

√
● Apply the wadding sheet in circular motion.
K. BIVALVING → Not too tight or loose
● Cutting the cast into two from the upper portion to the bottom ● Extend 2 to 3 cm beyond the intended edges of the splint, with
part. extra padding at each end of the intended splint border.
→ To relieve cast tightness
→ To facilitate X-ray
→ To allow inspection of extremity with cast

BSN-3C 12
● Wrap the casting material circumferentially, with each roll
overlapping the previous layer by 50 percent.
● Just before the final layer of casting material is applied, the
physician should fold back the stockinette and padding, and then
apply the final layer, molding the cast while the materials are still
malleable.
→ Finish before the cast hardens

R. RIZZER’S JACKET
● S-type cast (double curvature)
● Thoraco-Lumbar spine.
→ No cast on the inguinal and anal area

● Smoothen the cast with your palm to avoid indentions

● Allow to dry
→ Usually, 10 - 15 mins its already dry but complete dryness
takes 1 - 3 days
→ Do not use a blower

S. SHORT ARM CIRCULAR CAST

● Carpals & Metacarpals

YouTube Videos
● (1364) Synthetic casting short arm application_EN_by BSN
medical.mov - YouTube
● (1364) Applying an above elbow circular cast - YouTube
→ When applying plaster of paris, do not use gloves. Gloves T. SHORT ARM POSTERIOR MOLD
are only used when applying fiber glass. ● Carpals and metacarpals w/ open wound, inflammation, swelling
→ Plaster of paris will stick on the gloves → Posterior is mold, circular is cast
→ Mold is indicated for patients with open wound, swelling,
O. COLLAR CAST and inflammation
● Cervical Spine → Mold is usually color BROWN

U. LONG ARM CIRCULAR CAST

P. BODY CAST
● Radius - Ulna
● Lower thoracic and upper lumbar spine

Q. MINERVA CAST
● C -type scoliosis (single curvature)
● Upper thoracic and upper lumbar spines

BSN-3C 13
 V. LONG ARM POSTERIOR MOLD Z. SUGAR TONG
● Radius - Ulna affection with open wound, inflammation, and ● Compound fracture of humerus
swelling

W. FUNCTIONAL CAST AA. SHOULDER SPICA CAST

● Shaft of humerus with callus formation ● Humerus and Shoulder Joint
→ Functional cast in indented → All spica cast may “tuhod”
→ All cast that are indented have callus formation (3rd stage → affectation of shoulder and joint
of bone healing) already.

BB. AIRPLANE CAST

● First stage - hematoma formation ● Shaft of humerus with callus formation
● Second stage - callus formation
● Third stage - callus ossification
● Fourth stage - bone remodeling

CC. THUMB SPICA CAST

● First metacarpal bone

X. FUENSTER / MUNSTER CAST

● Radius - Ulna with callus formation
→ Indented

DD. PANTALON CAST

● fracture of the pelvis
● The vaginal and anal area are not
included.

Short arm circular cast → callus formation → changed to Fuenster cast

Y. HANGING CAST
● Shaft of Humerus
→ Have support
→ No callus formation
EE. SINGLE HIP SPICA CAST
● One hip and one femur
● Long leg cast does not include hip

BSN-3C 14
 FF. ONE AND ONE HALF HIP SPICA KK. SHORT LEG POSTERIOR MOLD
● Both hips and 1 femur ● Tarsals and metatarsals with open wound, swelling, and
● For TB of the hips inflammation

GG. DOUBLE HIP SPICA CAST

● Both hips and femur
LL. LONG LEG CIRCULAR CAST
● TB of the hips
● Tibia - Fibula
○ Inguinal area is not included

HH. SINGLE HIP SPICA MOLD

● One hip and femur with open wound, swelling, and inflammation
MM. LONG LEG POSTERIOR MOLD
● Tibia - Fibula with open wound, swelling, and inflammation

NN. WALKING CAST

II. FROG CAST
● Tarsals and metatarsals with callus formation
● Congenital hip dislocation ○ Similar to short leg circular cast but there is “tukod” below
● For babies ○ Can be used for ambulation (there is already callus)

JJ. SHORT LEG CIRCULAR CAST OO. PATELLAR TENDON WEIGHT BEARING CAST (PTB)
● Tarsals and metatarsals ● Tibia - FIbula w/ callus formation

BSN-3C 15
 PP. DELVITT CAST UU. CAST BRACE
● Distal 3rd tibia - fibula with callus formation ● Proximal 3rd tibia and fibula, distal 3rd femur

QQ. QUADRILATERAL CAST / ISCHIAL WEIGHT

BEARING CAST VV. INTERNAL ROTATOR BOARD
● Shaft of femur with callus formation ● Post hip surgery to prevent external rotation of knee
→ Can be used for ambulation → Px should stay in one position
→ Until inguinal area

WW. NIGHT SPLINT

● For post poliomyelitis with contractures of hip and knee
● Applied at night only

RR. CYLINDER CAST

● Fracture of the patella

XX. CAST CARE

SS. CYLINDER MOLD
● Patella with open wound, inflammation, and swelling
● Do not wet, cut or heat
● Allow the cast to dry naturally in circulating air
● If the cast becomes loose, cracked & soft it is no longer
keeping the injured body immobilized
● Do not push any objects inside the cast
→ Casts usually have 1 finger allowance
● Check the circulation of the finger or toes
● Don't scratch under the cast with sharp objects
● Trim rough edges
→ It might promote wounds and drying

IX. BRACES
● A mechanical support for weakened muscles, joints, and bones
in rehabilitation.

TT. BASKET CAST
● Patella with open wound which need frequent dressing
Functions
● Immobilize a joint or body segment
● Allows patient to walk without fatigue
● Maintain body alignment
● To control involuntary movements
● To prevent and correct deformity
● For support

A. SOFT COLLAR BRACE

● For cervical spine affection
● Made of cotton like material

BSN-3C 16
 B. SHANTZ COLLAR BRACE G. KNIGHT TAYLOR BRACE
● For cervical spine affection ● For thoracic spine affection
● Harder than the soft collar brace
● Lightweight

H. CHAIR BACK BRACE

C. PHILADELPHIA COLLAR BRACE
● For lumbo sacral spine affection
● For cervical spine affection
● Stronger support
● Chin is tilted

I. JEWETTE BRACE
● For dorso lumbar spine affection
D. FOUR POSTER BRACE
● Cervical and upper thoracic spine affection
● Used for spinal cord injury
● Removed when sleeping
→ Traction (Halo-Femoral) → changed to Four Poster Brace

J. MILWAUKEE BRACE
● For scoliosis, T9 and below

E. SOMI BRACE
● ISterno-Occipital-Mandibular Immobilizer

K. YAMAMOTO BRACE
● For scoliosis T9 and above
F. FORESTER BRACE
● For cervico-thoraco-lumbar spine affection

BSN-3C 17
 L. SCOTTISH RITE BRACE Q. OPPEN HEIMER
● For coxa plana or leg calve perthes disease ● For radial nerve injury
● Coxa plana or leg calve perthes - there is not enough oxygen
or blood that goes through the bone and becomes necrotic
→ Etiology is UNKNOWN

R. LIVELY FINGER SPLINT

● For fracture of the finger

M. UNILATERAL / BILATERAL LONG LEG BRACE

● For post poliomyelitis with residual paralysis

S. COCK-UP SPLINT
● To prevent wrist drop
● Worn for 23 hours
Unilateral Bilateral ● Removed during bath

N. SHORT LEG BRACE

● For clubfoot (talipes equinovarus) and for post-poliomyelitis with
residual paralysis

T. ARM SLING
O. DENNIS BROWNE SHOES
● To support affected upper extremity
● For clubfoot deformity
● For talipes equinovarus
● Start with cast (long leg circular cast) weekly, then when baby is
able to walk it is changed to Dennis Browne Shoes

U. SHOULDER STRAP
P. BANJO SPLINT
● For scoliosis
● For peripheral nerve injury
● Still worn at night while sleeping

BSN-3C 18
 V. BRAUN BOHLER SPLINT
● Fracture of the tibial plateau
● Used prior to BST

F. GIGLI SAW
● For amputation

X. HARDWARE
● A generic term that encompasses all metallic implants, including
joint prostheses

A. HEMOVAC
● To collect drainage post-op using negative pressure G. ANTIBIOTIC BEADS
● included in the I & O ● For osteomyelitis
● Beads are coated with antibiotics and put inside the bone. Will
dissolve on its own.
● E.g. Gentamicin, Tobramycin

B. BONE DRILL & DRILL BIT

● To bore holes on bones
● Have different sizes of drill beats
XI. FIXATION
● To stabilize a long bone fracture, a plate and screws outside the
bone or a rod inside the bone may be used.
● Screws are placed into the bone above and below the fracture,
and a device is attached to the screws from outside the skin,
where it may be adjusted to realign the bone.

C. OSTEOTOME (CHISEL)
● To get bone chips for bone grafts
● Orthopedic chisel

A. EXTERNAL FIXATION
D. SKIN STAPLER AND REMOVER
● Screws are placed into the bone above and below the fracture,
● To hold skin edges together
and a device is attached to the screws from outside the skin,
where it may be adjusted to realign the bone.

E. RONGEUR
● For cutting bone chips and putting chips in place
● Also have sizes, depending on the bone that will be cut

BSN-3C 19
Crutchfield Tong Mini Roger Anderson External Fixator (MINI RAEF)
● For cervical spine affection and for Pott’s disease affecting the ● For fracture of the fingers
cervical spine

Steinmann Pin/Holder
● For fracture, of hips, tibia, femur, fibula and humerus
Spanning External Fixator
● Facture of femur extended to tibia

Kirschner Wire/Holder
● For fracture of radius and ulna Ilizarov External Fixator
● For comminuted fracture, non-union (does not heal), mal union,
bone lengthening

Tower External Fixator/Interdental Wiring

● Fracture of mandible Delta Frame External Fixator
● Fracture of proximal 3rd or distal 3rd tibia
→ Triangle

Roger Anderson External Fixator (RAEF)

● For comminuted fracture of the long bone
→ Comminuted fracture - several pieces of bones were
broken
Hybrid External Fixator
● Periarticular fracture of ankle or knee joints
→ Triangle with half-ring

BSN-3C 20
Hoffmans External Fixator Y-Bone Plate
● For pelvic affection ● Supracondylar fracture of the humerus
→ Can’t be reused

T-Bone Plate/Buttress Plate

B. INTERNAL FIXATION ● Fracture of P3 or D3 of tibia
● To stabilize a long bone fracture, a plate and screws outside the
bone or a rod inside the bone may be used

Compression Hip Screw Fixator (CHSF)

● For intertrochanteric fracture of femur

Screws and Plates

Intramedullary Nail (IM Nail)

● Fracture of middle 3rd femur/ long bone

Cerclage Wire
● For fracture of patella tension band wiring
→ Made of titanium

Bone Plate With Screws

● To hold plates in place
→ Depends on physician where to insert
Procedure

IM Nails on X-Ray

BSN-3C 21
Intramedullary Nail Extractor XIII. PROSTHESIS
● To remove IM nail ● An artificial device to replace or augment a missing or impaired
part of the body

A. AUSTIN MOORE
● For Partial Hip Replacement Arthroplasty (no acetabulum)
● Made of metal

XII. SPINAL INSTRUMENTATION

● A method of straightening and stabilizing the spine after spinal
fusion, by surgically attaching hooks, rods, and wire to the spine
in a way that the stresses on the bones are redistributed and are
kept in proper alignment.

A. LUQUE ROD
● To correct scoliosis B. BIPOLAR HIP PROSTHESIS
● Metal rods fixed to each segment (vertebra) in the affected part ● Replacement of femoral head, neck and acetabulum
of the spine ● Total Hip Replacement Arthroplasty
● No need to wear a cast after the procedure
● Risk of injury to the nerves and spinal cord is higher

C. SPACER ANTIBIOTIC
● Replacement of infected hip prosthesis
B. HARRINGTON ROD ● Coated with antibiotic
● Oldest and most proven
● Used to straighten and stabilize the spine
when curvature is greater than 60 degrees
● Cheaper
● Advantages:
→ Simplicity of installation
→ Low rate of complication
→ Proved record of reducing the curvature
of the spine
● Body cast for about six months then body D. KNEE PROSTHESIS
braces for another 3 to 6 months while the ● Affection of patella, femoral, and tibial component; osteoarthritis
bone fusion solidifies

C. SUBLAMINAR WIRE
● To hold rods in place.

● Bone continuously remakes itself

● New bone is produced and old bone is removed
● Osteoblasts, the cells responsible for making bone, maintain
the balance of calcium in the blood and bone
D. PEDICLE SCREWS
● To stabilize rod placement

BSN-3C 22