Immobilization of the ankle

*The indications for the use of a U-shaped splint and an immobilization bandage are the same. (See also Overview of Fractures [ Overview of Fracture Treatment A fracture is a break in the integrity of a bone. Most fractures result from a single, significant force applied to a normal bone. In addition to fractures, there are also injuries to the musculoskeletal system .Read more information ]). Although the cast is the final treatment, temporary splinting is often recommended for some injuries until the swelling goes down. A plaster cast may be preferred in situations where the leg may be put under strain and the ankle should definitely be immobilized for more than 1-2 weeks. Conversely, immobilization shoes may be preferred when long-term immobilization is not required.

Modern immobilization techniques.

The complaints of ordinary people about plaster casts are not difficult to understand. A heavy bandage makes it very difficult to move. When it is attached to the leg, not only is it impossible to get to the hospital without help, but sometimes it is also impossible to reach your own kitchen. The plaster crumbs that fall off the inside of the bandage cause itching and discomfort and, in some cases, allergic reactions. In addition, the plaster gets wet, so showering after a fracture becomes a real adventure: you have to wrap the plastered area in plastic or literally bathe in the pieces.

However, all of this is just a temporary inconvenience that can be lived with. The doctors have more serious concerns. Lately, you've heard more and more often that a traditional plaster cast can cause the fracture to dislocate again. It is very difficult to check whether the bones are healing properly under a cast because the cast does not transmit X-rays well. In addition, if the cast is worn on the injured area for a long period of time, blood circulation is disrupted and muscles, joints and tendons are also affected. When a cast is applied and immobilized, they are not very functional, so they gradually lose their function. It is no coincidence that patients continue to limp for some time after the cast is removed. A common complication is local osteoporosis: Without stress, the bones near the fracture become less strong.

For this reason, specialists have recently developed techniques that use as little plaster as possible or replace it with other materials.

Plastic production, an alternative to traditional plaster

Plastic plaster, for example, is now considered a good alternative to good old plaster. It can also be called artificial or polymeric - the idea remains the same. This is a special material that the doctor first dips into water and then applies to the broken segment in a specific pattern. After a certain amount of time, the bandage dries and fixes the injured area.

In general, the principle of operation is not much different from that of the traditional dressing. However, there are some advantages: Plastic bandages are 4-5 times lighter than plaster bandages - you can move much easier while wearing them. Plastic bandages are not inferior to plaster, so you don't have to worry about a broken bone slipping or not growing together properly.

Plastic plasters are not afraid of moisture and you can shower with them. It is also breathable. Unlike a traditional plaster, it allows oxygen to penetrate the skin and water vapor to diffuse outwards. The result is less itching and irritation.

In addition, a plastic plaster looks better than a conventional plaster. If it gets dirty, it can simply be wiped clean with a cloth.

However, despite all the advantages, this material also has its disadvantages. This type of plaster should be handled by a doctor who is familiar with it, as the material hardens very quickly and it is unacceptable for the patient to apply the plaster themselves! In some cases this is even dangerous. In addition, removing the artificial plaster is more difficult than with conventional plasters. It is not possible to cut the artificial plaster with scissors - this requires special tools. Sufficiently experienced doctors work in our clinic, so after consulting the doctor, removing the cast will not take long.

placement

Fractures at the level of the distal tibial metaphysis are among the most common in the practice of an orthopedist and traumatologist. According to the literature, their incidence is between 12 % and 25 % of all fractures and between 40 % and 57 % of tibia fractures [1]. There is currently a trend towards more and more indications for surgical reconstruction of the ankle and ankle. Despite the rapid development of surgical techniques and the improvement of implants for immersion osteosynthesis, conservative treatment of this type of injuries remains of interest in our country.

Modern methods of external immobilization of the ankle joint are extremely diverse, but none of them exclude the development of a complication such as joint stiffness after immobilization. It is known that with prolonged immobilization, not only the function of the segment suffers. Morphological changes are observed in the synovial fluid, ligaments, cartilage, muscle fibers [2] and other elements involved in the formation and maintenance of normal joint function. It should be noted that immobilization contractures of the injured limbs are one of the main causes of disability and prolonged periods of disability (3). Therefore, treatment of ankle and other joint injuries must be comprehensive, holistic, and patient-centered. In addition to physical rehabilitation, intra-articular injectable medications show promise and may accelerate return of joint function and shorten healing time. Hyaluronic acid derivatives are used as the drugs of choice due to their properties. It is known that the use of hyaluronates increases the protective properties of the synovial fluid, reduces the production of pro-inflammatory cytokines and achieves a significant pain-relieving effect by improving the cushioning properties of the synovial fluid [4].

In the treatment of trauma, hyaluronic acid derivatives are most often prescribed to repair damaged periarticular and intraarticular structures and prevent dystrophic-degenerative changes in the joint. It is clinically proven that the incidence of post-traumatic ankle osteoarthritis decreases with intra-articular injection of hyaluronic acid, which is due to its ability to act on different parts of the pathological process and to its pronounced chondroprotective property [5].

Material and methods.

A prospective cohort study was conducted with 52 outpatients, including 27 (51.9%) women (mean age 43.9±13.1 years), who were admitted to the Tver Traumatology and X-ray Center from January 1, 2020 to September 30, 2020 for ankle fractures (ICD 10 code S82.5, S82.6). The study included patients of both sexes over 18 years of age with fractures of the ankle joint of varying complexity with a satisfactory bone fracture rate, treated conservatively with long-term immobilization of the ankle joint for more than 4 weeks. Inclusion criteria were age less than 18 years and ankle immobilization for less than 28 days. Patients with ankle fractures that were treated surgically were also excluded. The diagnosis was confirmed by an x-ray.

The follow-up examinations were carried out in the period after immobilization, ie the day on which external immobilization of the ankle joint was completed was considered the start of the study. After immobilization was removed, all patients were prescribed a standard set of exercises to promote ankle mobility. Total strain on the limbs was ruled out. The main study group consisted of 23 patients (12 women; mean age 45.5 ± 11 years) who received a single injection of the bionic hyaluronic acid preparation Flexotron® KROSS into the ankle joint on day 1 after immobilization. In the control group, 29 patients (15 women; mean age 42.7 ± 12.9 years) received a conventional rehabilitation measure without hyaluronic acid derivatives.

A goniometer was used to measure range of motion in 1° increments. Pain intensity was assessed using a visual analogue scale (VAS). Criteria for a positive rehabilitation outcome were recovery of a range of motion of 80 % of the injured ankle compared to the contralateral joint and the ability to bear weight on the injured limb.

complications

A 10 to 15 cm wide splint patch or fiberglass splint material* (wide enough to cover the area from the heel bone to the heads of the metatarsals on the surface of the sole, and long enough to reach from side to side and below the head of the fibula around the heel bone to run).

* Fiberglass and plaster typically come as single-layer rolls, but there are also commercially available prefabricated splint rolls that contain multiple layers of fiberglass/plaster and padding.

The patient should lie or sit on their stomach with their knee bent and their lower leg hanging over the edge of the bed.

Place a knitted stocking pad so that it covers the area from the calf to the middle of the foot.

Measure the splint material so that it extends from the lateral side of the tibia just below the head of the fibula to and around the sole of the foot and then back to the medial side of the tibia, forming a U-shaped splint.

Apply the bandage from the middle of the foot to the middle of the shin, slightly outside the splinted area, with each roll of bandage overlapping half the width of the previous roll, and periodically check the applied bandage across its width to ensure that Reduce risk of tissue compression.

Consider additional padding on bony prominences (e.g., medial and lateral malleolus).

Place a portion of the support material so that it extends from the lateral metacarpal to (and around) the sole of the foot, then rotate it back toward the metacarpal to form a U-shaped splint - this should be slightly shorter than that bandaged area.

Roll out the additional track material and place it back and forth along the first length until you have 6-8 layers (if using single layer rolls).

Place the splint material on the lateral side of the leg near the metatarsal bone, wrap it around the plantar surface of the foot, and then return to the medial side of the tibia.

Using your hands, not your fingertips, smooth the splint material to recreate the contours of the shin and ankle and fill in the gaps in the cast.

Wrap the elastic film over the splint material by starting at the distal edge and moving proximally, overlapping each previous wrap by half the width of the elastic film.

Place an additional knitted stocking pad and a layer of cotton wool over the untreated edges of the suture material.

Place the stocking pad so that it covers the area from the fibula to the middle of the foot, past the heads of the metatarsals.

Apply the bandage from the metatarsal heads to the tibia, proximal to the fibular head, slightly beyond the area covered by the splint; Apply the bandage so that each turn overlaps the previous one by half the bandage width, tearing the bandage at regular intervals across the width to reduce the risk of tissue compression.

Roll out a section of splinting material equal to the distance from the posterior surface of the tibia just below the head of the fibula to the plantar surface at the projection of the heads of the metatarsals - this section should be slightly shorter than the area covered by the cover.

Roll out the additional splinting material by folding it back and forth along the original length until you have 8-10 layers (if using single-layer rolls).

Alternatively, if you are using prefabricated stiffener material, cut a piece to the specified length.

Apply the splinting material to the back of the leg from the head of the fibula to the heads of the metatarsals.

Using your hand, not your fingertips, smooth the splinting material to follow the contours of the shin and ankle and fill the gaps in the cast.

Wrap the elastic band over the splinting material by starting at the distal edge and moving proximally, overlapping each previous wrap by half the width of the elastic band.

Check the condition of the distal nerves and vessels (e.g. capillary refill, distal sensitivity, finger flexion and extension).

How we treat contractures

Before attempting to restore movement in the joint, the cause of the restriction must be addressed. For example, if the contracture was caused by an injury, the first step is to determine what the injury is and how much it limits movement in the joint.

Do not start treating a contracture without making a diagnosis! This can only worsen the pain and complicate the condition.

If the contracture is caused by damage to the nerves that cause the muscles in the joint to contract, the activity of these nerves should first be restored. If the cause of the contracture is muscle damage, treatment should be aimed at restoring these muscles and only then at correcting the contracture itself.

Even long-term contractures following paralysis and paresis, severe fractures and dislocations, rheumatoid arthritis, burns and frostbite can be eliminated or significantly reduced through early and comprehensive treatment.

Such treatment may include special exercises, physiotherapy and massage. The specialists of our center have developed a unique set of joint exercises that can significantly increase the body's mobility. This complex is also successfully used to prevent contractures.

You can find our other treatment methods here.

What causes joint contractures?

Congenital joint contractures are rare. This also applies to the valgus foot.

In many cases, movement of a body part may be restricted following various injuries, traumas, or illnesses. For example, after an injury in the intraarticular or periarticular area (fracture, sprain, dislocation), scar tissue can form that prevents normal joint mobility.

Post-traumatic swelling of the joint capsule often prevents movement of the limb. This often occurs after a sprain.

Stiffness can also result from stress or trauma to the nervous system. Some people may experience stiffness in the neck after prolonged stress, or their legs may become stiff after a stroke.

Rheumatoid arthritis is the most common disease that limits mobility of the shoulder joints.

What not to do if you are immobile

We have provided a general overview of first aid measures for a fracture. Now let's look at how not to hurt him or her.

Before you immobilize the injured person, check whether he is bleeding. If bleeding is present, the first step is to stop it.

Once the bleeding stops, your powers end (even if you are a doctor, further action requires special conditions in a medical facility). An important lesson from this situation is that you should not try to straighten the bone. Also, do not attempt to move the injured person until the injured limb is secured.

Technique for immobilizing ankle, foot and toe fractures with the Kramer splint:

1)Bend the end of the rail (80 cm long) 20-25 cm at an angle of 90 0;

2)Adjust the splint to match the curvature of the calf muscle and heel area;

3) Applying the splint by placing cotton wool under the bony prominences;

Notice:For severe ankle fractures where there is a risk of lateral displacement of the foot, three splints should be used for immobilization: one on the posterior surface and two more on the inner and outer surfaces of the calf..

diagnostic methods

During the physical examination, the injury site is palpated and kinetic symptoms are assessed. An accurate diagnosis is made on the basis of x-rays.

The traumatologist orders an instrumental examination:

1. X-ray in three projections (anteroposterior, lateral and oblique). It helps to determine the type and nature of the injury.
2. MRI or CT examination of the articular surfaces. Indicated when flexor tendon impingement is suspected.
3. Ultrasound (required to rule out a joint fracture).

After a dislocated finger, coexisting anomalies may be identified during questioning and further instrumental examination; in this case, treatment of the spine and joints is required.

Therapies offered

The therapy is individually tailored to each patient. The doctor considers the examination findings, medical history and diagnostic data to determine treatment for the dislocated finger. Prognosis and treatment vary depending on the location and severity of the injury. In most cases the reduction is performed manually.

Before the finger is straightened again , The pain impulses are blocked by anesthetizing the nerve of the finger with a probe. Dorsiflexion reduction is performed by pulling the joint in the axial direction with a handle or bandage sling. The injured joint is immobilized with a plaster cast in a slightly flexed position for three weeks.

The hand sprain is also reduced using axial traction with force on the back of the hand. The injured area is then splinted for fourteen days.

After outpatient treatment, a stress test is carried out to assess the stability of the supporting ligaments. If a closed reduction is not possible due to severe damage to the ligaments, surgical intervention is indicated.

For uncomplicated injuries, full range of motion recovery is achieved. There is no pain during the rehabilitation period. If treatment of an old finger dislocation is unsuccessful, destructive joint processes (osteoarthritis, arthritis) can develop.

• Immobilization of the knee in osteoarthritis.
• dislocation of the ankle.
• Bones of the human ankle.
• Treated subluxation of the ankle.
• ligaments of the ankle.
• Injury to the ankle.
• Subluxation of the ankle.
• Damaged ligaments of the ankle.