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Preoperative Patient Care
Operative Techniques
E

Preoperative Plan

1

Template fracture

  • identify fracture pattern

2

Execute surgical walkthrough

  • describe key steps of the operation verbally to attending prior to beginning of case.
  • describe potential complications and the steps to avoid them
F

Room Preparation

1

Surgical equipment

  • casting materials
  • spica casting table
  • cast saw

2

Room setup and equipment

  • standard radiolucent table
  • c-arm fluoroscopy

3

Patient positioning

  • supine
G

Cover all areas to be casted with liner (stockinette or gore-tex)

P

1

For a traditional one and a half spica cast, cover from the nipple level to the distal tibia on the injured leg and to the distal femur on the uninjured leg

  • alternatively, cover proximally to the lowest rib

2

For a single leg spica cast, cover the inferior trunk and injured leg down to the distal tibia

Pearls
  • For many low energy mechanism femur fractures a walking spica cast can be used
H

Position on spica table

1

Transfer the patient to the spica table

  • secure the arms over the chest or to arm board on spica table
  • assistant holds the patient's legs in appropriate position
I

Reduce the fracture

P

1

Reduce fracture by optimizing positioning of the injured leg

  • goal is to have distal fragment match the position of proximal fragment
  • for mid-diaphyseal fractures, the proximal fragment is usually pulled into flexion, abduction and external rotation by psoas, hip abductors, hip external rotators
  • Therefore distal fragment needs to be flexed, abducted and externally rotated to match this
  • injured leg is positioned so that hip and knee are in mild flexion (more flexion if proximal fracture), in abduction around 20-30 degrees, and in external rotation around 10-15 degrees
Pearls
  • For mid-diaphyseal fractures, the proximal fragment is usually pulled into flexion, abduction and external rotation
J

Pad chest and abdomen with towels and overwrap stockinette/liner with cast padding

1

place folded towels over chest and abdominal area (up to 2 inches in thickness)

  • to allow full respiratory excursion

2

overwrap stockinette/liner with cast padding

  • 3 layers of cast padding, with additional padding on bony prominences (iliac crest, greater trochanter, patella, fibular head)
K

Evaluate reduction and apply fiberglass

P

1

Use c-arm fluoroscopy and determine if reduction is adequate

  • acceptable shortening: birth to 2yrs=15 mm; 2 to 5yrs =20mm
  • acceptable varus/valgus angulation: birth to 2 yrs=30 degrees; 2 to 5 years=15 degrees
  • acceptable anterior/posterior angulation: birth to 2 years=30 degrees ; 2 to 5 years =20 degrees
  • CHECK ROTATIONAL ALIGNMENT! an AP at the hip should match an AP of the knee and a lateral of the hip should match a lateral of the knee

2

Apply fiberglass to stabilize fracture alignment

  • overwrap the cast padding with fiberglass leaving approximately a half inch of uncovered cast padding at the edges
Pitfalls
  • Reinforce the lateral inferior buttock as this area often does not have sufficient fiberglass/strength
L

Mold the cast and reevaluate with c-arm fluoroscopy

P

1

Apply a strong valgus and recurvatum mold as these fractures tend to fall into varus and procurvatum when the patient wakes up and the psoas and abductors pull on the proximal piece

Pearls
  • Ideally intraoperatively the fracture is aligned in valgus and recurvatum demonstrating some overcorrection of this

2

Use c-arm fluoroscopy to confirm reduction is still adequate

  • if reduction is unacceptable, cast can be adjusted, e.g. cast wedging
  • if reduction is still unacceptable, options are to change cast or transitioning to external fixator or flexible intramedullary nails
N

Trim window for perineal care and ensure cast edges are not sharp

1

Trim window for perineal care

2

Remove towels over chest and abdomen

3

Ensure cast edges are not sharp - can apply moleskin to edges

Postoperative Patient Care
 

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