Chain of Infection

Protozoa are much larger than bacteria.

They are the simplest single-celled organisms of the
animal kingdom. Parasitic protozoa absorb nutrients
from the body of the host.
The causative agent is any capable of pro- Parasites live on or inside other organism
ducing disease. ( called”host) at the expense or those organisms.
Bacteria are simple, one-celled microbes They don’t usually kill their host but take only the
with double cell membranes that protect them from nutrients they need.
harm. They reproduced rapidly and are considered
as the protect them from harm. They reproduce rap-
idly and are considered as the most common cause
of fatal infection diseases. They are classified ac-
cording to:
 Shape ( cocci, bacilli, spirillae )
 Need for oxygen (aerobic, anaerobic )
 Response to straining ( gram (+) or (-), or acid-
fast )
 Motility (motile, non-motile)
 Tendency to capsulate ( encapsulated, capsulat-
ed); and
 Capacity to form spores (spore-forming, non-
spore forming)
A spirochete is a bacterium with flexible,
slender, undulating spiral rods that possess cell wall. Reservoir of infection refers to the envi-
There are three forms of spirochete that cause a ronment and objects on which an organism survives
disease: and multiples. The following are reservoir of infec-
1. Treponema tion:
2. Leptospira Human reservoir
3. Borilia  Frank cases or the very ill
Viruses are the smallest known microbes.  Sub-clinical or ambulatory
They cannot replicate independently of the host  Carriers
cell’s rather, they invade and stimulate the host’s An incubatory carrier is a person who is incubating
cells to participate in the formation of additional the illness.
viruses. A convalescent carrier is a person who is at the re-
Rickettsiae are small, gram (-), bacteria- covery stage of illness but continues to shed the
like microbes that can induce life threatening infec- pathogenic organism.
tions. Like viruses, they require a host cell for repli- An intermittent carrier is a person who occasionally
cation. They are usually transmitted through the bite sheds the pathogenic organism
of anthropod carries like lice, fleas, ticks as well as A chronic or sustained carrier is a person who al-
their waste products. The rickettsiae disease are: ways has the infectious organism in his or her sys-
1. Rocky mountain spotted fever tem.
2. Typus fever, and Animals
3. Q Fever Non-living things
Chlamydiae are smaller than rickettsiae but  The portal of exit is the path or way through
larger than viruses. Theses ae the common cause of which the organism leaves the reservoir. Usual-
infection of the urethra, bladder, fallopian tube and ly, this is where the organism grows. The com-
prostate gland. The most common chlamydial infec- mon portals of exit re the;
tion is transmitted through sexual contacts. 1. Respiratory system
Fungi area found almost everywhere on 2. Genitourinary tract (GUT)
earth. The live in organic matter soil, water, animals 3. Gastrointestinal tract (GIT)
and plants. They thrive either inside or outside the 4. Skin and mucous membranes, and
body and may be harmful or beneficial. Fungi are 5. Placenta ( in transplacental transmission)
beneficial in the manufacturing of cheese, yogurt,
beer, wine, and certain drugs.

1
 Mode of transmission is the means by which Emerging problems in infectious diseases
the infectious agents passes through from the
portal of exit of the reservoir to the susceptible
host. This is easiest link to break the chain of 1. There is an increasing number of microorgan-
infection. These are form of modes by which isms that are developing resistance to a like-
infectious agents can be transmitted: wise increasing number of available antimicro-
Contact transmission is the most common mode of bials.
transmission. There are three types: 2. There is an increasing number of individuals in
Direct contact refers to a person-to person transfer the state of immunosuppression. These are indi-
of organism viduals who have survived cancer, leukemia,
Indirect contact occurs when the susceptible per- and the like, but are now susceptible to inva-
son comes in contact with a contaminated object sion by any type of organism, including non-
Droplet spread is transmission through contact pathogenic ones.
with respiratory secretions when the infection 3. Individuals with serious disease who survive
coughs, sneezes or talks. Microbes carried in drop- longer and are expected to undergo more exten-
lets can travel up to three feet (one meter). The or- sive surgical procedures are prone to infectious
ganism is not suspended in the air but settles on a disease.
surface. 4. The use of indwelling lines and implanted for-
Air-borne transmission occurs when fine microbial eign bodies has increase. Healthcare profes-
particles or dust particles containing microbes re- sionals/workers rendering care to patient who
main suspended in the air for a prolonged period. have these are more susceptible to infection.
The infectious disease is spread by air current and is
inhaled by a susceptible host. Principles underlying Medical
Vehicle of transmission is the transmission of infec-
tious disease through articles or substances that har- and Surgical Asepsis
bor the organism until it is ingets by or inoculated
into the host.  The patient is a source of pathogenic mi-
Vector-borne transmission occurs when intermedi- croorganisms.
ate carriers, such as fleas, flies, and mosquitoes,
transfer the microbes to another to another living  The patient’s microorganisms leave
things. through specific route.
A portal of entry is a venue through which the or-
ganisms gains entrance into the susceptible host.  There are always microorganisms in the
The infective microbes use the same avenues when
environment, which in some individuals
they exit from the reservoir
Susceptible host the human body has many defenses and under certain circumstances can cause
against entry and multiplication of organism. When illness.
the defenses are good, no infection takes place.
However, in a weakened host, microbes launch an  Microorganisms are harmful to man can be
infectious diseases. transmitted by direct and indirect contact.
 Spread of infection from source to others
Illness following an entrance of organism into the
body depends on the host’s… can be prevented by various method to stop
1. Age, sex, genes, and constitution; the spread as close to the source as possi-
2. Nutritional and fitness statuses and environ-
ble
ment factors
3. General condition ( physical, emotional, and  The effectiveness of medical and surgical
mental illness);
asepsis dependent on the conscientiousness
4. Absence of or abnormal level of immuno-
globin; of those carrying them out.
5. Underlying disease (diabetes mellitus, lympho-
ma, leukemia, neoplasm or uremia); and  In obderving medical asepsis, areas are
6. Treatment with certain antimicrobials, cortico- considered contaminated if bear or are sus-
steroids, radiation, or immunosuppressed drugs
pected having pathogens.
2
  In observing surgical asepsis, areas are Cleaning, Disinfecting and Sterilization
considered contaminated if touched by any
object is not sterile.

Breaking the Chain of Infection

 Handwashing
 Cleaning, Disinfecting, Sterilization
 Use of Barriers
 Isolation System
 Surgical Asepsis

Handwashing

Cleaning

The physical removal of visible debris by

washing, dusting or mopping surfaces that are con-
taminated. Soap is used for mechanical cleaning.

Handwashing is the single most important

infection control practice. All caregivers, clients
and family member should learn handwashing tech-
inique. Microorganisms are transient flora until the
hands are washed.
Soap and water and alcohol base hand-
scrubs are effective preparations for removing tran-
sient microorganisms. Wash hands before and after Disinfecting
every client contact.
Effectiveness of handwashing ius greatly The chemical or physical processes used to
influence by adequate function and thoroughness of reduce the number of potential pathogens on an
surface cleansed. object’s surface. But spores of the pathogens are
Handwashing for medical asepsis is done not necessarily destroyed.
by holding lower than the elbows. Hands are more
contaminated than lower arms.
Wash hands using running water, soap, and
friction for 15-30 seconds on each hand. This is to
mechanically loosen and remove dirt on all hands
surfaces and under fingernails.
Ideally, turn faucet with clean towel. Keep
fingernails short and avoid nail polish to prevent
from harboring microorganisms.
Always wear gloves during client care
when the skin is abraded.

3
Sterilization  Keep soiled items or equipment from
touching the clothing.
The complete destruction of all microor-  Instruct client to cover mouth and nose
ganisms, including spores, leaving no viable organ- when coughing and sneezing.
isms.  Avoid rising dust, do not shake linens.
 Clean least contaminated area first then
Methods of Sterilization move to more contaminated areas.
 Practice segregation of wastes.
Steam Sterilization
 Sterilize objects suspected of contaminat-
Autoclaving is sterilization using supersat- ing pathogens.
urated steam under pressure. This method is non-
 Use practices of good personal hygiene to
toxic inexpensive, sporicidal and able to penetrate help prevent of spread of microorganisms.
fabrics rapidly, if it used to sterilize surgical dress-
ings. Use of Barriers
Gas Sterilization Techniques that prevent the transfer of
pathogens from one person to another are referred
Ethylene oxide is a colorless gas that can to as “barriers”. The most commonly used barriers
penetrate (fabrics) plastic, rubber, cotton and other as follows:
substances. This is used to sterilize oxygen or suc- 1. Mask
tion gauges, BP apparatus, stethoscope and cathe- 2. Caps and shoe coverings
ters. 3. Gloves
4. Private rooms
5. Waterproof disposable bags for linens and trash
Radiation
6. Labeling and bagging of contaminated equip-
ment and specimens
Ionizing radiation penetrates deeply into
7. Control of airflow into the sterile areas and out
objects. This is used in sterilizing drugs, food and of contaminated areas
other heat sensitive. 8. Goggles of face shields

Chemicals Equipment and refuse handling

These are effective disinfectants, these are Articles and soiled linens by any body flu-
used for instruments and equipment such as glass
id should be placed in water proof bags before they
thermometer. Chlorine is used for disinfecting wa-
ter. are removed from the client’s bedside. Waste seg-
regation and disposal should ensure prevention of
Boiling water transfer of microorganisms.
This is the lest expensive for use in home,
items like glass baby bottles should be boiled for Categories of institutional wastes are follows;
atleast 15 minutes.
Infectious waste
Medical aseptic practice to be implemented  Blood and blood products
during nursing care  Pathology laboratory specimens
 Laboratory cultures
 Body parts from surgery
Wash hands frequently especially;  Contaminated equipment (suction, catheter,
 Before handling foods urinary catheters, nasogastric tubes)
 Before and after using toilet  Food
 Before and after performing nursing proce-  Unrinsed infant and adult diapers
dure
 Before and after each patient contact Injurious waste
 Before and after touching one object etc.
 Needles
4
 Scalpel blades Transmission Based Precautions
 Lancet  Airborne Precautions- these are used
 Broken glass for microorganisms transmitted by
 Pipettes
small particle droplets that can remain
Hazardous waste suspended and become widely dis-
 Radioactive materials pensed by air currents.
 Chemotherapy solutions and their containers  Droplet Precautions- these are used for
and other caustic materials. microorganisms transmitted by larger
particle by droplets
Isolation System  Contact Precautions- these are used
with organism that can be transmitted
Isolation precaution are classified by hand or skin to skin contact.
as standard precautions transmissions-
based precaution and protective isolation. Protective isolation
 Implemented to prevent infection for
Standard precaution are intended those resistance to infection or body
to prevent transmission of bloodborne and defenses are lowered or compromised
moist body substance pathogens. (leucopenia, immunosuppressive medi-
cations)
\Wear clean gloves when touching;  The client should be placed in private
 Body fluids, blood, secretions, excre- room
tions and items containing body sub-  Restrict visitors
stances  Only cooked or canned fruits are al-
 Mucous membrane lowed
 Non-intact skin
Surgical Asespsis
Perform hand washing properly
 Direct contact with blood, body fluids, Required in the following situa-
secretions and excretions tions; Surgical procedures
 After removing gloves All procedures that can cause break
 Between patient contacts in the skin or mucous membrane. Complex
dressing changes and wound care.
Wear a mask, eye protection and Care for high risk groups
face shield during procedures and patient (transplant recipient, burn clients, clients
care activities that are likely to generate with cancer).
splashes or sprays of blood, body fluids,
Principles Under Surgical Asepsis
secretions, and excretions etc.
Moisture causes contamination
Remove soiled protective items
promptly  Prevent splashing of liquids in the ster-
ile fields.
Clean and reprocess all equipment  Place sterile objects on sterile water
before reuse by another patient  Rationale: microorganism travel more
easily through moist environment.
Discard all single use items prompt-
ly in appropriate container.
5
Never assume that an object is sterile A collective and individual “sterile con-
 Ensure labeled as sterile science” is the best method of enhancing
 Check the integrity of the packaging sterile technique
 Verify the expiration date Rationale: periodic review of procedures
 When in doubt, consider non sterile and infection control surveillance report
enhance everyone’s sterile technique
Always face the sterile field
Rationale: objects that are out of the line of Traction
vision may be inadequately contaminated.
Is now used much less commonly
Sterile articles may touch only sterile arti- due to improved implants and surgical
cles surfaces techniques for the treatment of fractures.
Rationale: anything considered unsterile However, management by traction
may transfer microorganisms to sterile ob- remains essential for those patients who
ject if touches. age or condition means that surgical treat-
ment is not appropriate.
Sterile equipment or areas must be kept Traction is the application of a pull-
above the waist and on top of the sterile ing force to a part or parts of the body for
field the treatment of bone and muscle disorders
Rationale: waist level is the limit of good or injuries.
visual field Counter-Traction, traction in oppo-
site direction. Traction can be used to:
Prevent unnecessary traffic and air currents  Relieve pain due to muscle spasm
around the sterile area  Restore and maintain alignment of
 Close doors bone following fracture or dislocation
 Unfold drapes or wrappers slowly  Rest injured or inflamed joints whilst
 Do not sneeze or cough or talk exces- maintaining a functional position
sively over the sterile object  Allow movement of joints during frac-
 Do not reach across the sterile fields ture healing
 Move around a sterile field to reach for  Prevent or gradually correct deformities
an object due to contraction of soft tissue caused
by disease or injury
Open, unused sterile object are no longer
sterile after the procedure
Rationale: Once protective wrapping have
been removed, the article is being contami-
nated by air so it must be discarded and
resterilized before it used

A person is considered sterile who become

contaminated must restablish sterility.
Rationale: if a scrubbed person punctures
the gloves or is contaminated by touching
an unsterile object, he or she must change
the contaminated article
Balanced Skeletal Traction

6
Methods of Application Cotrel – combination of head halter and
Manual pelvic girdle traction; for scoliosis
The pulling force is applied manu-
ally usually by the hands.
It is also required during any adjust-
ments to the traction arrangement which
necessitates the temporary release of the
traction weight.

Cotrel

Pelvic Girdle Traction – for lumbo-sacral

affection; for HNP (Herniated Nucleus Pul-
posus)

Cervical Manual Traction

Skin
The application of a traction force
over a large area of skin which is then
transmitted via the soft tissues to the bone.
The grip on the body is less secure
than with skeletal traction.

Pelvic Girdle Traction

Hammock’s Suspension – pelvic affections

Skin Traction

Kinds of Skin Traction

Non – adhesive Traction: it is preferable if Hammock’s Suspension

the traction is only to be on for a short peri-
od of time.
7
Head Halter Traction – for cervical spine Bryant’s Traction – hip and femur affection
affection for children ages 6 years old or 3 years old
and below; congenital hip dislocation

Head Halter
Bryant’s Traction
Boot Cast Traction – special type of trac-
tion for hip and knee contractures and post-
polio with residual paralysis Buck’s Extension – hip and femur affection
for adults

Boot Cast

Adhesive Traction: it should not be used Buck’s Extension

with fragile or damaged skin as removal
may cause further skin injury. Zero Degree – for the neck of the humerus
Dunlop Traction – supracondylar fracture
of the humerus
Skeletal
The application of a traction force
directly to the bones through metal pins or
wires allowing large forces to be transmit-
ted directly to the bone.
Sites for the insertion of metal pins
for skeletal traction include the proximal
end of the tibia, the calceneum, the distal
femur, the skull, and the olecranon.

Dunlop Traction 8
 Skeletal Traction 90-90 degrees

Types of Skeletal Traction Overhead Traction – Supracondylar of the

Halo Femoral Traction – Severe Scoliosis humerus.

Halo Femoral Traction Overhead Traction

Halo Pelvic Traction – Scoliosis Balanced Skeletal Traction (BST) – hip

and femur affection

Halo Pelvic Traction

Balanced Skeletal Traction
90-90 Degrees – Sub-trochanteric of the
femur 9
CARING FOR A PATIENT WITH Provision of supportive therapy – offer
TRACTION book to read, something to listen radio or
Assessment – assess the patient as to level television, discovers interest.
of understanding, consciousness.
Spiritual Aspect – know his religion, en-
Provision of general comfort. courage relatives to give spiritual, commu-
a. Skin care – head to toe, focus on the nication, visiting chaplain.
sponging of the affected extremity. Diversional activities – divert attention.
HOW TO SPONGE? 2 basins with face
towel and soap. Remove sling one by one REMOVAL OF TRACTION
and sponge. 1. Apply rest splint.
b. Changing of linen. 2. Hang suspension weight on the first
c. Provide bedpan as needed - serve bedpan (1st) pulley.
on unaffected side, provide pillow at the 3. Complete removal of suspension
back and provide privacy. weight. Remove the knot on the Pear-
d. Perineal care son attachment and Thomas splint.
4. Manual traction on the Steinman pin
Potential complications: holder, remove the traction weight on
a. Upper respiratory - PNEUMONIA – the third (3rd) pulley, secure the trac-
bronchial tapping and deep breathing. tion rope on the rest splint another on
b. Bedsore – good perineal care, proper the Thomas splint and Pearson attach-
skin care, turning left buttocks once in a ment.
while.
c. Urinary and kidney problem – good peri-
neal care, increase fluid intake.
CASTS
d. Bowel complication – fear of apparatus, The application of a cast is a specialized
no privacy, lack of fluids, perineal care. technical skill that requires education,
e. Pin site infection – observe for s/sx of training, practice and constant review of
infection, loosening pin tract, pus com- competence to ensure patients receive
ing out, foul smelling, fever. Aseptic tech- safe, high quality care. Most casts should
nique and proper referral to DIC.
f. Deformity – contracted knee, atrophy of be applied by practitioners with a spe-
muscles, foot drop, and joint contractures. cialist casting qualification and experi-
ence.
Provision of Exercises
a. ROM exercises with the use of trapeze. A cast is a rigid device used to provide
b. Deep breathing exercises. support and protection following injury and
c. Static quadriceps exercises, alternate surgery and for other musculoskeletal con-
contractions and relaxation of quadriceps ditions that require immobilization. Casts
muscles. are constructed from flexible bandages im-
d. Toes pedal exercises. pregnated with material which hardens
when ‘cured’ following contact with water.
Nutritional Status – depending on the sta- The bandage is usually dipped in water,
tus of patient. wrapped around the limb or body part and
then held in position until the material
Psychological Aspect – fear of unknown, hardens. This provides a firm support that
fear of death, fear of the apparatus, fear of follows the contours of the area it encases.
losing job, financial fear. 10
 A number of materials are used for Assistance may be required with some
casting. Plaster of Paris casts are most of- activities of daily living including:
ten used immediately following injury or
Toileting – a stool to place the leg on if in a
surgery as they are relatively cheap and
long leg cast and a commode and/or hoist if
easy to apply. A lighter, more robust, syn- mobility is poor.
thetic cast can then be applied for a longer
period of time once swelling has subsided. Eating and drinking – food and fluids with-
The choice of cast depends on applier pref- in easy reach; making sure the patient has
erence and the instructions of the consult- their food cut up if their arms are in casts;
ing surgeon. equipment such as non-slip mats and
adapted cutlery.
FUNCTIONS OF CASTS
Dressing – advice on the best clothing to
Support . Supporting and restricting move- wear or adaptations to be made such as
ment following fracture until healed. Velcro fastenings.

Rest. Resting soft tissues following frac- Mobility – assessment of mobility and aids
ture, strain or sprain to reduce swelling and required with instructions for use.
muscle spasm
Sleeping – can be difficult. Extra pillows
Immobilization. To rest a joint in disease or and bed cradles may help along with short
hold a joint in place following dislocation, term medication to help re-establish a sleep
particularly if ligaments are damaged. Also pattern.
used following muscle or tendon surgery to
aid healing. Casts may be removed or bi-valved at the
end of treatment,when a new cast is needed
Caring For the patients with Cast or if there is a problem with the cast or
limb causing neurovascular compromise.
It is important that practitioners Every orthopaedic practitioner should be
have an understanding of how a patient able to safely remove or bi-valve a cast.
will cope with life in a cast. A comprehen- Bi-valving involves cutting the cast in half
sive assessment by the multidisciplinary along both sides so that one half of the cast
(MDT) team may be required to ensure the can be removed whilst the limb is still sup-
patient will be able to manage safely after ported with the other half. The same pro-
discharge. cess should be used when removing a cast,
This will depend on previous levels allowing the bottom half of the cast to be
of independence, the ability to accept a dif- used as a splint while the limb is inspected.
The limb can then be carefully lifted out of
ferent level of self-care than before, availa-
the cast to remove it.
bility of assistance from others and the Casts are bi-valved or removed using either
practical advice they are given. plaster shears or an oscillating plaster saw.
Practitioners must receive training and be
competent in the use of either piece of
equipment. Prior to cutting, the cast should

11
be marked on the medial and lateral sides Plaster saws have an oscillating circular
so that the cutting lines do not pass over blade which vibrates back and forth at high
any bony prominences or fragile skin. speed rubbing through the casting material.
It must have a vacuum attached to ensure
Before removing a cast it is important the dust is collected in keeping with health
to:
• Check the patient’s details and the written and safety regulations. The blade is held at
instructions for removal. right angles to the cast and light pressure is
• Prepare the area and equipment to be applied to make it cut without dragging the
used. saw along the cast. The blade is then re-
• Give verbal information prior to removal moved and reapplied above or below the
to gain the patient’s cooperation and con- original cut in an in-and-out motion.
sent.
• Demonstrate the equipment to be used on
the patient prior to use to allay anxiety.
SPLINT
• Adequate pain relief must be provided.  It is a device used for support or immo-
• The patient must be positioned comforta- bilization of a limb or the spine.
bly and the part of the body to have the cast  It can be used in multiple situations in-
removed must be supported in the correct cluding temporary immobilization of
position. potentially broken bones or damaged
• Privacy and dignity must be maintained at joints and for joints during activity.
all times.  Two types of splint materials are plas-
• The patient’s cast should be carefully as- ter and fiber glass.
sessed prior to removal to ensure the cor-
rect equipment is used for cast removal. Functions:
1. To promote healing and early weight
• Mark the cutting area medially and later-
bearing.
ally avoiding bony prominences.
2. To support, maintain and protect rea-
• Written information must be given to the
ligned bone.
patient following cast removal.
3. To prevent or correct deformity.
All types of casts can be removed with
4. To immobilize.
plaster shears or an oscillating saw. Syn-
thetic casts require special saw blades Types of Splint
made of tungsten
Volar Splint or Dorsal Splint
Plaster shears are blunt, and crush plaster A splint constructed on the back of
of Paris between two hinged ‘jaws’. The the hand to inhibit full extension of one or
blade of the shears should be passed be- more of the finger joints and/or the wrist.
tween the cast and the padding with the Indications:
hand nearest the cast being kept parallel to  Sprains of the wrist or soft tissue inju-
the limb and kept still. Once the cast is cut ries.
through on both sides it can be opened with  Fractures of the second, third, and
the plaster spreaders and the padding cut fourth metacarpals.
 Fractures of the second, third, and
all the way through with bandage scissors.
fourth phalanges.
 Positioning for rheumatoid arthritis.

12
 Positioning in the treatment of carpal  Laceration over the joints of the second
tunnel syndrome (median nerve com- and third phalanges or metacarpals
pressive neuropathy), sometimes in
conjunction with a metacarpophalange-
al unit. Thumb Spica Splint

Usually offer additional immobili-

zation for the thumb area. These braces are
indicated for soft tissue injuries, gamekeep-
er injuries, collateral ligament support and
avulsion fractures of the thumb.

Volar Splint or Dorsal Splint

Radial Gutter Splint

Used for fractures and severe

sprains to the second and third metacarpals
and phalanges (pointer and middle fingers).
Indications:
 A thumb spica splint (see the image
below) can be used for various injuries,
including the following:
 Scaphoid injuries
 Lunate injuries
 First metacarpal fractures
 Injury to the ulnar collateral liga-
ment (UCL)
 Positioning for de Quervain tenosyno-
vitis
Radial Gutter Splint
Indications: Ulnar Gutter Splint
 A radial gutter splint can be used for
various injuries, including the follow- Isolated fractures of the distal
ing: fourth or fifth metacarpal bones, also
 Soft-tissue injuries to the second and known as boxer's fractures, are among the
third fingers more common fractures seen by primary
 Fractures of the second and third meta- care physicians. One simple and proven
carpals method for immobilizing boxer's fractures.
 Fractures of the second and third pha-
langes
 Positioning for rheumatoid arthritis
13
  Initial treatment of fractures of the
shafts of both the radius and ulna
(“both-bone” fractures)
 Postoperative protection of the forearm
or wrist.
Anteroposterior Splint

Is most commonly used for initial

Ulnar Gutter Splint support of the injured extremity (whether
surgery is planned or not) and for postoper-
Indications: ative immobilization of internally fixed
 An ulnar gutter splint (see the image fractures.
below) can be used for various injuries
to the upper extremities, including the
following:
 Soft-tissue hand injuries to the fourth
and fifth fingers
 Fourth and fifth metacarpal fractures
 Fractures of the fourth and fifth phalan-
ges
 Positioning for rheumatoid arthritis or
osteoarthritis
Sugar Tong Splint Anteroposterior Splint

Used for the forearm or wrist. They Indications:

are named "sugar-tong" due to their long,  A posterior elbow splint is primarily
U-shaped characteristics, similar to a type used to stabilize the following injuries:
of utensil used to pick up sugar cubes.  Fractures or soft-tissue injuries of the
elbow.
 Fractures or soft-tissue injuries of the
proximal radius or ulna that require im-
mobilization of the wrist and elbow

Posterior Long Arm Splint

Posterior long arm splinting is used
in the management of multiple upper-
Sugar Tong Splint extremity injuries. Splints stabilize injuries
by decreasing movement and providing
Indications: support, thus preventing further damage.
 Initial treatment of distal radius frac-
tures.
 Initial treatment of isolated radius or
ulna fractures
14
 SUGAR-TONG or STIRRUP SHORT LEG
Sugar-tong splints are used to stabi-
lize injuries of the forearm and wrist by
preventing forearm rotation and wrist mo-
tion. These splints may be used to maintain
alignment of broken bones or to protect a
patient’s forearm or wrist after surgery.
Sugar-tong splints are long and U-shaped,
not unlike a utensil used to pick up sugar
Posterior Long Arm Splint cube.
Indications:
 Distal humerus fractures

 Proximal forearm fractures

 Radial head and neck fractures

 Olecranon fractures
 Severe ligamentous injuries of the el-
bow

SHORT-LEG POSTERIOR
Also known as "Short-Leg Posterior
Splint". Adding a coaptation splint (stirrup)
to the posterior splint eliminates inversion / SUGAR-TONG or STIRRUP SHORT
eversion - especially useful for unstable
fracture and sprains. Indications:
 Initial treatment of distal radius frac-
tures
 Initial treatment of isolated radius or
ulna fractures
 Initial treatment of fractures of the
shafts of both the radius and ulna
(“both-bone” fractures)
 Postoperative protection of the forearm
or wrist
POSTERIOR LONG LEG SPLINTING
SHORT-LEG POSTERIOR Posterior long leg splinting is used to stabi-
Indications: lize injuries by decreasing movement and
 Distal tibia/fibula fracture providing support, thus preventing further
 Tarsal/metatarsal fracture damage. Splinting also alleviates extremity
 Reduced dislocations pain, edema, and further soft-tissue injury
 Severe sprains and promotes wound and bone healing.
 Achilles tendon rupture (equinus posi-
tion) 15
Splints can be used for immobilization of  Limiting early motion also may reduce
an extremity before surgery or as a tempo- edema and, theoretically, improve the
rizing measure before orthopedic consulta- immune system’s ability to combat the
tion. infection
 Patients with multiple traumatic inju-
ries should have fractures and reduced
dislocations adequately splinted while
other diagnostic and therapeutic proce-
dures (eg, focused assessment with so-
nography for trauma [FAST] examina-
tion or computed tomography [CT]) are
completed; immobilization decreases
blood loss, minimizes the potential for
further neurovascular injury, decreases
the need for opioid analgesia, and may
decrease the risk of fat emboli from
long-bone fractures.
Indications
 Posterior long leg splinting is indicated
for the immobilization and support of
POSTERIOR LONG LEG SPLINTING various knee injuries. In many EDs, the
use of prefabricated knee immobilizers
Splints, rather than circumferential
has replaced traditional posterior long
casts, are often the treatment of choice in
leg splinting; however, the plaster long
the emergency department (ED) because
leg splint remains particularly useful
they allow for continued swelling and thus
when knee immobilizers are unavaila-
are associated with a lower risk of com-
ble and in the following situations:
partment syndrome. Follow-up for defini-
 Extremities that are too large for knee
tive care with an orthopedist should occur
immobilizers
1-5 days after splint application.
 Treatment of angulated fractures
In addition to immobilization, pos-
 Temporarily immobilization of knee
terior long leg splinting may offer addition-
injuries that require immediate opera-
al benefits specific to the particular injury
or problem being treated. tive intervention or orthopedic referral.
Examples include the following:
 Splinting deep lacerations that cross the
knee joint reduces tension on the CARING FOR THE PATIENTS WITH
wound and helps prevent wound dehis- SPLINT
cence
 Immobilizing tendon lacerations may
Discharge instructions, Return to the emer-
facilitate the healing process by reliev- gency department if:
 You have increased pain.
ing stress on the repaired tendon.
 Your fingers or toes are numb or tin-
 The discomfort of inflammatory disor-
ders such as tenosynovitis or acute gout gling.
is greatly reduced by immobilization  You feel burning or stinging around
 Cellulitis over the joint should be im- your injury.
mobilized for comfort. 16
 Your nails, fingers, or toes turn pale,  Do not pull the padding out of your
blue, or gray, and feel cold. splint. The padding inside your splint
 You have new or increased trouble protects your skin. You may develop a
moving your fingers or toes. sore on your skin if you take out the
 Your swelling gets worse. padding.
 The skin under your splint is bleeding  Do not put your hard splint in the wa-
or leaking pus. ter , even with a plastic bag over it. A
 Your hard splint gets wet or is dam- wet splint can make your skin itchy,
aged. and may lead to infection.
 You have a fever.
 Your splint feels tighter. ORTHOPEDIC HARDWARE
 You have itchy, dry skin under your (POC)
splint that is getting worse.
 The skin under your splint is red, or An orthopedic hardware or im-
you have a new sore.
 You notice a bad smell coming from plant is a medical device manufactured to
your splint. replace a missing joint or bone or to sup-
 You have questions or concerns about
your condition or care. port a damaged bone. The medical implant

How to care for your splint: is mainly fabricated using stainless steel
 Wait for your hard splint to harden and titanium alloys for strength and the
completely. You may have to wait up
to 3 days before you can walk on a plastic coating that is done on it acts as an
plaster splint. artificial cartilage.
 Check your splint and the skin around
it each day. Check your splint for dam- Internal fixation is an operation in
age, such as cracks and breaks. Check
your skin for redness, increased swell- orthopedics that involves the surgical im-
ing, and sores. Loosen the elastic band- plementation of implants for the purpose of
age around your splint if it feels too
tight. repairing a bone. Among the most common
 Keep your splint clean and dry. Keep
types of medical implants are the pins,
dirt out of your splint. Before you
bathe, wrap your hard splint with 2 lay- rods, screws and plates used to anchor frac-
ers of plastic. Then put a plastic bag tured bones while they heal.
over it. Keep the plastic bag tightly
sealed. You can also ask your External Fixation is a technique of
healthcare provider about waterproof fracture immobilization in which a series of
shields.
 Do not put powders or deodorants in- transfixing pins is inserted through bone
side your splint. These can dry your and attached to a rigid external metal
skin and increase itching.
 Do not try to scratch the skin inside frame. The method is used mainly in the
your hard splint with sharp objects. management of open fractures with severe
Sharp objects can break off inside your
soft tissue damage.
17
Roger Anderson External Fixator Hybrid External Fixator
For comminuted fracture of the long bone. For periarticular fracture of the ankle/knee
joint.

Delta Frame Fixator

For fracture of proximal/distal tibia.

Compression Hip Screw Fixation

(CHSF)
For inner trochanteric fracture of femur.

Spanning External Fixator

For fracture of femur extended to tibia.

Buttress Plate/T-plate
Prevents proximal displacement of the
fragment. It is also added to enhance the
stability and to counter axial load on the
Hoffman’s External Fixator
fracture, especially in osteoporotic bone.
For pelvic affection.

18
X-pinning/Y-pinning Intra Medullary Nailing (IMN)
For supracondylar fracture of humerus. Fracture of middle 3rd femur/long bone.

Harrington Rod Instrumentation

For scoliosis. Spacer Antibiotic
Replacement for hip prosthesis.

Luque Rod Hemovac

For scoliosis. For collection of drainage under pressure.

19
Gigli Saw Chisel and Osteotome
For amputation.

Total Knee Arthroplasty Prosthesis Illizarov External Fixator

For fracture of patella, femoral, and tibial For comminuted fracture nonunion, mal
component – Osteoarthritis bone. union, bone lengthening.

Crutchfield Tong
For cervical spine affection.

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 BRACES (Orthopedic) NECK BRACES

An orthopedic brace (also orthosis Neck braces stabilize the cervical

or orthotic) is a device used to: spine after neck injury or surgery, or as an
1. Immobilize a joint or body segment alternative to surgery. They are the most
2. Restrict movement in a particular direc- common type of spinal braces. There are
tion several types available, Including:
3. Assist movement
4. Reduce weight-bearing forces Soft collar. A flexible brace placed around
5. Correct the shape of the body the neck, it is typically used after a more
rigid collar has been worn for the major
Neck and back braces are most often used
to treat: healing. It is used as a transition to wearing
1. Low back pain no collar.
2. Trauma
3. Infections
4. Muscular weakness
5. Neck conditions
6. Osteoporosis

Braces immobilize and support the

spine when there is a condition that needs
to be treated. They can put the spine in a
neutral, upright, hyper-extended, flexed or
lateral flexed position.

Spinal braces are used for a variety of rea-

sons:
1. Control pain
Soft collar
2. Lessen the chances of further injury
3. Allow healing to take place
4. Compensate for muscle weakness
5. Prevent or correct a deformity Philadelphia collar. A more rigid/stiff col-
lar with front and back pieces that attach
They offer safe, non-invasive way with Velcro on the sides, it is usually worn
to prevent future problems or help you heal 24 hours a day until the physician has it
from a current condition. Though the ef- removed. This collar is used for conditions
fects of bracing are primarily positive, they such as a relatively stable cervical fracture,
can lead to a loss of muscle function due to cervical fusion surgery or a cervical strain.
Another similar type is Miami cervical
inactivity. Bracing can sometimes lead to
brace.
psychological addiction, so that even when
a person is healed and ready to be taken off
the back brace, he or she feels dependent
upon it for physical support.

21
 that goes around the head and secures it to
the skull with four metal pins. The ring
then attaches by four bars to a vest that is
worn on a chest to bear the weight of the
brace. The halo is worn 24 hours a day un-
til the spine injury heals.

Philadelphia collar

Sterno-occipital mandibular immobiliza-

tion (SOMI) Device. This brace holds the
neck in a straight line that matches up with
the spine. It offers rigid support to a dam-
aged neck and prevents the head from
moving around. With this brace, the neck is Halo
unable to bend or twist. The restriction of
motion helps the muscles and bones to heal Trochanteric belt. This device is usually
from injury or surgery. prescribed for sacroiliac joint pain or to
stabilize pelvic fractures. The belt fits
around the pelvis, between the trochanter
(a bony portion below the neck of the thigh
bone) and the iliac (pelvis) ridges or crests.
The belt is about five to eight centimeters
wide and buckles in front, just like a regu-
lar belt.

Lumbosacral and sacroiliac belt - These

help to stabilize the lower back. It is usual-
ly made of heavy cotton reinforced by
lightweight stays. The pressure can be ad-
Sterno-occipital mandibular immobiliza- justed through laces on the sides or at the
tion (SOMI) Device back of the belt. Lumbosacral belts range
in width of 10 to 15 and 20 to 30 centime-
Halo. Used to immobilize the head and
ters. The sacroiliac belt is used to prevent
neck, this is the most rigid of the cervical
motion by compressing the joints between
braces. It is only used after complex cervi-
the hipbone and sacrum at the base of the
cal spine surgery or if there is an unstable
spine.
cervical fracture. It has metal ring (halo)
22
Corset. This type of brace provides rigid William Brace. A rigid brace with no verti-
support for the back. Corsets way in length. cal uprights in the middle, allowing the pa-
A short corset is typically used for low tient to bend.
back pain, while a longer one is used for
problems in the middle to lower thoracic
spine. When people think of corsets, they
usually conjure up images of women from
earlier times who used them to make their
waists appear smaller. Today, in the treat-
ment of back problems, corsets refer to a
type of back brace that extends over the
buttocks and is often held up by shoulder
straps. Like the corsets of old, these corsets
have laces at the back, sides or front. There
are also metal stays that provide the appro-
priate rigidity and support for the back. William Brace

Chair-back brace. A rigid brace that holds

the lumbar spine in the neutral position and
limits lateral and rotating movement of the
lower spine.

Corset

Rigid Brace. Usually prescribed for low

back pain and spinal instability when
standard back supports are not stiff enough. Chair Back
Rigid braces usually have upright pieces in
the rear that curve to the shape of the lower Raney flexion jacket. A rigid brace that
spine and pelvis, with bands across the tho- reduces curvature of the lumbar spine by
racic region of the spine. There are also holding it in a neutral tilt.
fabric straps on the braces that provide
pressure in the front. Some common types
of rigid braces are:
23
 Strengthening the muscles of the upper
extremities
Extremities and shoulder girdle
Give the patient following instruction:
 Flex and extend the arms slowly while
holding traction weights. Gradually in-
crease the poundage of weight and the
number of repetition to increase the
strength and endurance.
 Do push-ups while prone position .
 Squeeze a rubber ball (increases grasp-
ing strength
 Raise head and shoulder from bed;
stretch the hand forward as far as possi-
Raney Flexion Jacket ble.
 Sit up on bed or chair
 Raise the body from the chair by push-
Principles of Crutch Walking ing hands against the chair seat (or mat-
tress).
AMBULATION  Raise the body out of the seat. Hold.
Means ‘’To WALK’’. Ambulating Relax.
the patient keeps him more active and im-
proves muscle tone and strengths in his Teaching the crutch walking
legs. 1. Have the patient wear well-fitting shoes
CRUTCH WALKING with feet slightly apart and away from the
Crutches are artificial supports that wall.
assist patients who need aid in walking be- 2. Before using the crutches, have the pa-
cause of disease, injury or a birth defect. tient standby a chair on the unaffected leg
to achieve balance.
Preparation for Crutch walking 3. Position the patient against from the wall
GOALS: Develop power in the shoulder with the head neutral position.
girdle and upper extremities that bear the 4. TRIPOD POSITION – Basic crutch
patients weight in crutch walking. stance for balance and support.
Strengthen and condition the patient. A. Crutches rest approximately 20-25 cm
(8-10 inches) in front of and to the side of
Strengthening the Muscle Needed for Am- the patient.
bulation B. a taller patient requires a wider base:
Instruct the patient as follows: whereas shorter patient needs narrower
1. For quadriceps setting: base
a. contract the quadriceps muscle while 5. Teach the patient to support his/her
attempting to push the popliteal area weight with his/her hands: weight borne on
against the mattress and raise the heel. the axillae can damage the brachial plexus
b. Keep the muscle contracted for a count nerves and produce ‘’CRUTCH PARALY-
of 5.
SIS’’
c. Relax the muscle for the count of 5.
d. Repeat this exercise 10-15 times hourly

24
Teaching the crutch gait THREE-POINT GAIT
1. Crutch walking requires balance and co- This is use when one leg is in-
ordination and has high-energy cost. It can volved. The crutch-foot sequence is as fol-
be acquired with diligent and regular prac- lows:
tice. [Link] crutches and the involved lower leg
2. Allow the patient to practice balancing are moved forward simultaneously.
with crutches while leaning against the [Link] the stronger lower extremity is
wall. moved forward while the most of the body
3. Instruct the patient to shift his/her body
weight in different positions while standing
crutches
4. The selection of the crutch gait depends
on the type and severity of the disability
and the patient’s physical condition, arm
and trunk strength, and/ or body balance
5. Teach the patient at least two gaits-a
faster gait to be used for swiftness and a
slower one to be used in crowded places.
6. Instruct the patient to change from one
gait to another- this relieves fatigue be-
cause a different combination of muscle is
used.
weight is put on the crutches
CRUTCH GAITS
FOUR-POINT GAIT (FOUR-POINT TWO-POINT GAIT
ALTERNATIVE CRUTCH GAIT) This is a progression from the four-
point gait that allows faster ambulation.
1. This is a slow but stable gait. The pa- Crutch- foot sequence:
tient’s. The patient’s weight is constantly Weight is borne on both lower extremities
being shifted. and both together.
2. Only patients who can move each leg Advance right foot and left crutch together.
separately and bear a considerable amount Then, advance left foot and right crutch
of weight on each of them can use the four- together.
point gait.
3. Crutch- foot sequences:
a. Right crutch
b. left foot
c. left crutch
d. right foot

25