Effectiveness of ice packs in reducing skin temperature under casts

Revolution in orthopedic immobilization materials: A comprehensive review

Immobilization material has slowly revolutionized since 3000 BCE from traditional plaster to modern day synthetic casting tape, including other sustainable immobilization material. This revolution is driven by the search for superior casting material that possesses excellent mechanical and load-bearing properties, non-toxicity, excellent healing rates, patient satisfaction and eco friendliness. Even though the new materials have been evolved, the traditional plaster still remains a material of choice owing to its excellent skin conformability, low cost and availability. This paper aims to present a comprehensive review on the technique of immobilization, existing orthopedic immobilization (casting and splinting) materials and complications associated with immobilization (mainly casting) which aimed to assist the medical practitioners and researchers in casting material improvements and selection. Nine immobilization materials are comprehensively discussed for their desirable properties, drawbacks and the required improvements to the composition, along with the most common cast complications ranging from superficial pressure sores to compartment syndrome and Deep Vein Thrombosis. . This paper identifies that among the existing material, plaster casts are still highly used due to their cost benefit and the ability to fit patients into full body casts, while synthetic material is too rigid and has a higher probability of causing complications such as compartment syndrome and deep vein thrombosis. Patients show a higher preference in using synthetic casts for short term and body extremity casting as they are comparatively more comfortable. New materials such as Woodcast shows good promise but their mechanical characteristics and comfort are yet to be critically analyzed. However, there exists an imminent requirement to upgrade existing material as well as to introduce novel promising sustainable material for long term immobilization.

Confronting the Opioid Crisis: Practical Pain Management and Strategies: AOA 2018 Critical Issues Symposium

The United States is in the midst of an opioid crisis. Clinicians have been part of the problem because of overprescribing of narcotics for perioperative pain management. Clinicians need to understand the pathophysiology and science of addiction to improve perioperative management of pain for their patients. Multiple modalities for pain management exist that decrease the use of narcotics. Physical strategies, cognitive strategies, and multimodal medication can all provide improved pain relief and decrease the use of narcotics. National medical societies are developing clinical practice guidelines for pain management that incorporate multimodal strategies and multimodal medication. Changes to policy that improve provider education, access to naloxone, and treatment for addiction can decrease narcotic misuse and the risk of addiction.

A Quality Improvement Initiative Reduces Cast Complications in a Pediatric Hospital

BACKGROUND

Casts, while frequently used as routine treatment in pediatric orthopaedic practice, are not without complications. At our large tertiary care pediatric hospital, the baseline rate of all casting complications was 5.6 complications per 1000 casts applied (0.56%). We tested the hypothesis that we could use quality improvement (QI) methodology to decrease the overall cast complication rate and improve patient care.

METHODS

We initiated a QI program implementing concepts derived from the Institute for Healthcare Improvement models, including Plan-Do-Study-Act cycles, to decrease our cast complication rate. A resident casting education program was developed with a competency "checklist" to ensure that casts are applied, bivalved, and removed in a safe and standardized manner to prevent patient harm. AquaCast Saw Stop Protective Strips were required to be applied with every cast application. A review of our facility's processes and procedures determined adequate measures were in place to effectively manage inventory and maintenance of cast-saw blades.

RESULTS

With the multimodal QI intervention, our cast complication rate was reduced to 1.61 complications per 1000 applications, a >90% improvement.

CONCLUSIONS

Implementation of QI concepts to perform a QI initiative resulted in a shift toward fewer cast complications, leading to overall improved patient care at a large tertiary pediatric hospital.

LEVEL OF EVIDENCE

Level II-prospective cohort study.

Skin temperatures generated following plaster splint application

Heat is generated during the exothermic reaction associated with plaster splint application. The amount of heat generated is affected by the plaster thickness, dipping water temperature, and extremity elevation method. The authors assessed the effect of these variables on skin and plaster temperatures. Short-leg posterior splints were applied to noninjured extremities on a volunteer using 2 protocols. Following splint application, the splinted leg was elevated in 4 ways: on plastic-covered urethane pillows in cotton pillowcases, on cotton blankets, on ice packs (short-term cryotherapy) placed on top of cotton blankets, or with heel elevation to promote free air circulation. Skin and plaster temperatures were monitored at 1-minute intervals. The maximum skin temperature generated and the average time that skin temperature was 40 °C or higher were recorded.

Effect of pressure applied during casting on temperatures beneath casts

BACKGROUND

Burns and pressure sores are common injuries during cast application. Various factors such as water temperature, padding, and cast material layers may play a role in these injuries; however, the effect of cast molding on temperatures and pressures has not been investigated. This raises the following questions, does the application of molding during cast application: (1) alter skin level temperatures in a variety of cast materials? and (2) risk inducing either thermal injury or pressure necrosis?

METHODS

An upper extremity model was created to measure pressure and temperature underneath casting materials. Cast padding, water bath temperature, and cast thickness were standardized. A 3-point mold was simulated using 3 casting materials-Fiberglass only, Plaster Only splint, and Plaster splint overwrapped with Fiberglass-while pressure and temperature were recorded.

RESULTS

: Pressure application led to a statistically significant (P<0.0001) increase in temperature at the sites where the mold was applied although absolute temperature did not reach the theoretical burn threshold of 49 to 50°C for the casting materials studied. With pressure applied, the Plaster/Fiberglass combination reached an average peak temperature of 47.9°C, which was maintained for up to 6 minutes. Neither Fiberglass nor Plaster Only reached peak temperatures of this magnitude (average of 42.7 and 43.6°C, respectively). Peak (369 mm Hg) and highest residual (21 mm Hg) pressures were below harmful levels.

CONCLUSIONS

Pressure application during casting is a risk factor for burn injuries. Care should be taken when molding a plaster splint overwrapped in fiberglass by waiting until the plaster has fully cooled.

CLINICAL RELEVANCE

Combined with other known risk factors, the pressure from molding a cast could increase the likelihood of causing cutaneous burns.

Is it possible to decrease skin temperature with ice packs under casts and bandages? A cross-sectional, randomized trial on normal and swollen ankles

INTRODUCTION

There is a general belief that the presence of a cast or a bandage eliminates the lowering effects of skin temperature when local cold therapy applied on the surface of the cast or bandage. The purpose of this study is to determine the magnitude of temperature changes at the skin of the ankle after the application of frozen ice packs to the surface of various casts and bandages both in normal and swollen ankles.

MATERIALS AND METHODS

Thirty-two healthy subjects (Group A) and 12 patients with Grade III inversion type acute ankle sprain (Group B) were randomly divided into four groups. The sensor of the digital thermometer was secured to the ankle over the anterior talo-fibular ligament in every subject before placement of a bandage or cast. Robert Jones bandage, elastic support bandage, a below-knee plaster cast and synthetic below-knee cast were applied in groups 1, 2, 3 and 4, respectively. Two frozen ice packs were placed around the cast or bandage at the level of sensor, and skin temperatures were recorded.

RESULTS

The skin temperature under dressings and casts decreased significantly relative to the baseline temperatures with local cold therapy in all groups. The fall in the temperature with cryotherapy in group A showed a three-phase pattern of change between groups 1 and 2, groups 2 and 3 and groups 2 and 4 during the experiment. The fall in the skin temperature with ice packs differed significantly between groups 1 and 3, and also groups 1 and 4 from the beginning till the end of the experiment. There was no significant difference between groups 3 and 4 in terms of skin temperature fall with cryotherapy during the whole experiment. The results were similar in group B.

CONCLUSION

A bandage or cast does not prevent measurable skin temperature lowering by frozen ice packs both in normal and swollen ankles.

Soft-tissue injury associated with closed fractures: evaluation and management

Determination of the severity of injury to the soft tissues is an important component of patient assessment and affects management of closed fractures. The response of soft tissue to blunt injury involves microvascular and inflammatory processes that produce localized tissue hypoxia and acidosis. Incisions placed through such compromised tissue can lead to wound breakdown and deep infection. Therefore, recognizing the signs of soft-tissue injury is the foundation for successful management of closed fractures. Many treatment options, including splinting, cryotherapy, compression, and delayed surgery, help limit further soft-tissue injury and facilitate its rapid recovery before surgical intervention. Emerging surgical techniques based on improved management have resulted in decreased rates of soft-tissue complications.

Continuous-flow cold therapy after total knee arthroplasty

Cryotherapy is widely used as an emergency treatment of sports trauma and postoperatively especially after anterior cruciate ligament reconstruction. Studies in the literature on the effect of cryotherapy after total knee arthroplasty (TKA) have been limited and controversial. In this prospective study, 60 primary TKAs were done on 30 patients (all staged bilateral TKAs). For every patient, 1 TKA had a continuous-flow cooling device applied over the surgical dressing immediately postoperatively. The other TKA in the same patient (control TKA) was done 6 weeks later and had no cooling device. The study compared the range of motion, the volume of hemovac output and blood loss, visual analog pain score, analgesic consumption, and wound healing in the 2 limbs of the same patient. This study showed that continuous-flow cold therapy is advantageous after TKA because it provides better results in all the areas compared.

The Effects of Cryotherapy Applied through Various Barriers

The purpose of this study was to investigate the differences in skin temperature during ice application through a dry towel and a dry elastic bandage compared to application on bare skin. Nine subjects completed a 30-min treatment session that consisted of 0.68 kg of cubed ice applied under three conditions: through a dry towel, through a dry elastic bandage, and directly on the skin (control). Following the removal of the ice, all subjects were monitored for 20-min for skin temperature (S temp). There was a significant interaction in S temp between the control (12.50 ± 4.39 °C) and dry towel (23.48 ± 2.88 °C) conditions, the control (12.50 ± 4.39 °C) and dry elastic wrap (27.47 ± 2.36 °C) conditions, and the dry towel (23.48 ± 2.88 °C) and dry elastic wrap (27.47 ± 2.36 °C) conditions. The findings indicated that using a barrier (dry towel or dry elastic bandage) limits the temperature-reducing capacity of the ice and therefore its potential physiological effects.