Chapter 8. Treatment methods for injuries of the musculoskeletal system

The variety of methods aimed at achieving fracture fusion is divided into two groups - conservative and operative. Their importance and relevance in the treatment of fractures is approximately the same. More than once in the history of the development of traumatology, with the advent of new invasive technologies, a bias was formed towards surgical techniques, but later the balance was restored again. This is due to the fact that there is no and cannot be a single universal method of treatment; each method has its own indications and contraindications, advantages and disadvantages. Today, because of wide opportunities, which are opening with the development of new implants and surgical technologies, surgical treatment in most cases is considered preferable.

At the same time, conservative methods, even if less "impressive" but in experienced hands used according to indications are sometimes not less effective, although they require much more trauma skills, medical erudition, and a deep understanding of the principles of fracture treatment.

Conservative methods include treatment with position, plaster casts, and constant traction. They can be used both as basic and auxiliary ones (i.e., as an addition to other methods). Currently, conservative treatment as the main method is used, as a rule, in the treatment of stable fractures without displacement or with a slight displacement, as well as in cases of absolute contraindications to surgery.

In addition, there are methods aimed at stimulating fracture healing, relieving pain, and reducing local inflammation.

Treatment by position

Positional treatment is often referred to as a functional method, but this is incorrect. The functional method provides for the complete or partial preservation of the function of the damaged segment for the entire period of treatment. In position treatment, immobilization is performed without the use of external or immersion clamps. Examples include the treatment of stable fractures of the pelvic bones in the "frog position" (knees bent and apart, heels brought together), stable compression fractures of the lumbar spine on a reclining roller with strict bed rest.

The advantage of this method is the absence of the need to wear fixing bandages, the disadvantage - the need for long-term adherence to a fixed position, which is unfavorable for the elderly, as well as patients suffering from chronic somatic diseases. The scope of application of the method is limited to a small range of specific locations of damage, as well as contraindications associated with a long-term fixed position of the patient.

Soft bandages

Soft bandages can be used as an independent method of therapeutic immobilization or as an auxiliary one. For the purpose of medical immobilization, as a rule, gauze bandages or gauze cloth are used. Some of the most common types of soft bandages are made in a factory method (for example, a scarf bandage on the upper limb, soft fixation bandages made of elastic fabric on the knee, elbow, ankle, wrist joints).

The main advantages of soft dressings as an independent means of therapeutic immobilization are a comfort for the patient (minimal additional weight of the dressing, no hard pressure on the tissues and underlying bone protrusions), as well as the possibility of constant monitoring of the state of tissues under the dressing. The disadvantages include insufficiently rigid immobilization, the need for periodic correction or even shifting the bandage when the fixation is weakened, or the bandage is dirty. In this regard, soft dressings have a limited scope. Careful adherence to the recommended treatment regimen by the patient is also necessary.

The most common bandages are Desault, Velpeau, "snakelike", Delbe rings, scarf, figure-8 (Fig. 8.1). Gauze bandages can also be used as an auxiliary bandage in combination with others (for example, with a plaster cast).

Fig. 8.1. Soft gauze bandages: a) Desault; b) Velpeau; c) "snakelike"; d) scarf; e) Delbe rings; f) figure-8

Plaster casts

Gypsum is dehydrated calcium sulfate, which, when added with water, turns into a mushy mass and hardens quickly. Despite the periodic appearance of a number of alternative (primarily polymeric) materials, gypsum has been the optimal material for external immobilization of damage for more than 100 years. The main advantages of gypsum are ease of use, plasticity, wide possibilities for modeling the dressing during hardening, strength after drying, high hygroscopicity and sorption capacity, good thermal conductivity, low cost. These and a number of other advantages more than compensate for the disadvantages (the need for special storage conditions to avoid moisture ingress, a relatively considerable weight).

Previously, plaster casts were prepared just before use by rubbing gypsum powder into gauze bandages. Currently, non-bulk plaster bandages of factory production are used. There are also hardening bandages not with gypsum, but with polymer impregnation, but they cannot completely replace gypsum (the greater rigidity of the bandage creates a danger of compression of tissues with the increase of edema).

For imposition, use plaster bandages or splints (rolling a dry bandage in several layers). A plaster bandage or splint is immersed in warm water, waiting for the cessation of air bubbles (a sign of complete soaking), taken out of the water and squeezed. The splint is straightened and carefully smoothed on a flat table or suspended. When the gypsum hardens, an exothermic reaction occurs, and the dressing heats up somewhat. It is necessary to distinguish the hardening of gypsum (when it loses its plasticity) from its complete drying. For the hardening of gypsum, few minutes is enough. The colder the water, in which the gypsum is soaked, the longer the hardening takes. An increase in water temperature accelerates this process. At a water temperature of 15 °C, gypsum hardens in about 10 minutes, at 40 °C - in 4 minutes. The optimal water temperature is considered about 40 °C. At the same time, soaking gypsum in very hot water may not lead to hardening at all. To completely dry the plaster (especially massive dressings), it takes from several hours to 1-2 days, but this process can be accelerated by treating the wet bandage with special drying lamps or a household hair dryer. Until the gypsum is completely dry (when it acquires maximum strength), even minor movements in the fixed joints should be excluded, since this can lead to the formation of cracks and folds on the flexor surface and cause not only immobilization failure but also local tissue compression, the formation of abrasions and bedsores.