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COoiyuLA^^-^^^JL^
LAURENCE WELT
r T- • "^j ^' vir on c o V c 1 "t" i
LAURUNCE WEtT...
CUUAjUOL^tlL^
LAURENCE WELT
^^r .Laurence ^ 'il^i
LAURUNCE WELT...
PLASTER OF PARIS
AND
HOW TO USE IT
BY
MARTIN W. WARE, M. D.
Ad)un<5l Attending Surgeon Mount Sinai Hospital ; Surgeon to the Good Samaritan Dis>
pensary ; InAructor of Surgery The New York PoSt Graduate School
NEW YORK:
SURGERY PUBLISHING COMPANY
92 WILUAM STREET
1906
Copyrighted December, 1906.
Surgery Publishing Co.
V7 21
\^ ^
PREFACE
The material for the subject-matter of this book is
based on ten years' dispensary practice in the very large
joint disease and fracture service (5,000 cases) of the
Good Samaritan Dispensary.
The embodiment in book form of this experience and
of what has heretofore been but a fragmentary consid-
eration of the subject is due to the suggestion of Dr.
Walter M. Brickner, Chief of the Surgical Out-patient
Department, Mt. Sinai Hospital, whose valuable assist-
ance in editing these pages is hereby thankfully acknowl-
edged. Thanks are due to Dr. Maurice Green for his
aid in the preparation of the chapter on Plaster of Paris
in Dental Surgery. The illustrations are for the most
part reproduced by Dr. Erwin Reissman from original
photographs and sketches ; others from standard text-
books of surgery.
Martin W. Ware.
1 198 Lexington Avenue, December, 1906.
108(>r>H
TABLE OF CONTENTS
CHAPTER I
The Plaster of Paris Bandage. — Materials. — Manu-
facture of the Bandage. — Storage. — Bandages of
Commerce. — Molded Splints. — Protection from
Soiling. — The Immediate Preparation of the Band-
ages for Use. — Chemical Adjuvants. — Protection
of the Skin. — ^application and Precautions. — Re-
moval of the Plaster Bandage. — Replacement of the
Cast. — Toilet After Bandage is Completed. — Dis-
posal of Refuse Pages 1-15
CHAPTER II
The Application of the Plaster of Paris Bandage to
Individual Fractures. — Fractures Suitable for Plas-
ter. — General Considerations. — Posture. . .Pages 16-19
CHAPTER III
Fractures of the Upper Extremity. — Fractures of
One or Both Bones of Forearm. — Fracture of Shaft
of Humerus. — Fracture of the Elbow Joint. — Colles'
Fracture. — Fracture of the Thumb. — Fracture of
the Metacarpal and Carpal Bones. — Time Limit for
Removal of Plaster Casts in Fractures of Upper
Extremity Pages 19-24
CHAPTER IV
Fractures of the Loiver E.rtrernities. — General Rule.
— Fractures at the Hip Joint. — Plaster of Paris
Hip Spica. — Fractures of the Femur (Shaft). —
Fractures of the Lower Half of the Tibia and at
V.
TABLE OF CONTENTS
the Ankle Joint. — Fractures of the Foot. — Fenes-
trated Plaster of Paris Dressing for Compound
Fractures. — Methods of Fenestration. — The Am-
bulatory Plaster of Paris Cast. — Fracture of the
Patella. — Fracture of the Olecranon Process. —
Compound Plaster of Paris Splints. — Segmented
Splints. — Suspended Splints. — Heated Splints. —
I 'ages 25-37
CHAPTER \'
Molded Plaster of Paris Splints. — Methods of Ap-
plication. — Bavarian Splint. — Hemp Splint. — The
Tricot Molded Splint. — Cole's Splint. — Braatz
Spiral Molded Splint. — Molded Splint for I^^racture
of the Forearm. — Gutter Splint Pages 38-53
CHAPTER \T
Plaster of Paris in Orthopedic Surgery. — Plaster of
Paris Corset. — Vertical Suspension. — Trimming
the Jacket. — Horizontal Suspension. — Goldthvvait's
Method.— Horizontal Method in Hammock. — The
Bradford Frame. — Particulars About the Jacket. —
Lorenz Bed. — Plaster Collar and Jacket. — Torti-
colHs. — Hip Joint Disease. — Application of the Hip
Spica. — Knee Joint Disease. — Ankle Joint Disease.
— Flat Foot. — Congenital Hip Dislocation. — Club-
Foot. — Wolff's Method Pages 54-72
CHAPTER VIl
Plaster of Paris in Dental Surgery. — Mixing the
Plaster. — Preparation of the Patient. — Difficult Im-
pressions. — Making the Plaster Models. — The Sep-
arating Media Between Impressions and Models. —
Interdental Splints. — Plaster Models of the Body.
— Re])air and Preservation of Models Pages 73-82
VI-
LIST OF ILLUSTRATIONS
PAGE
Fig. I. Preparing plaster bandage by hand 2
Fig. 2. Plaster of Paris cradle 4
Fig. 3. Plaster bandage ready for use 5
Fig. 4. Freeing bandage of frayed edges 6
^^S' 5* Cuff of cotton at the upper and lower limbs
of the plaster 10
Fig. 6. Strip of metal incorporated in the bandage. 11
Fig. 7. Dividing plaster cast with Gigli saws
placed under the bandage ii
Fig. 8. Plaster of Paris cast removed in lateral
halves with mitre or Gigli saw 12
Fig. 9. Grooves cut in the cast with mitre saw... 13
Fig. lb. Mitre saw 13
Fig. II. Stilles' shears ' 13
Fig. 12. Removing the cast from the limb 14
Fig. 13. Reapplying the cast with adhesive straps.. 14
Fig. 14. Plaster of Paris bandage for fracture of the
forearm 19
Fig. 15. Plaster cast for lower third of the arm,
elbow, or the upper third of the forearm. 22
Figs. 16 and 17. Cast for fracture of the thumb or
carpal bones 23
Fig. 18. Metal hip rest 26
Fig. 19. Pelvis raised on super-imposed fists of as-
sistant 27
Fig. 20. Plaster spica of hip 27
Fig. 21. Plaster cast for fracture of upper half of
leg 28
Fig. 22. Tricot hose investment in fracture of the leg 29
VII.
LIST OF ILLUSTRATIONS
PAGE
Fig. 23. Assistant holding foot for application of
plaster bandage 30
Fig. 24. Patient holding foot for application of
bandage 31
Fig. 25. Plaster of Paris splint with two fenestra. . 32
Figs. 26, 27, 28. Veneering strips to strengthen the
cast 34, 35
Fig. 29. Bridging strips of metal permitting motion
and inspection of the joint 35
Fig. 30. Wire worked into the two sections of cast
for suspension 36
Fig. 31. Molded splint with wire hooks for sus-
pension 36
Fig. 32. Illustrated plaster splint with wire for sus-
pension 37
Fig. 33. Impregnated plastic fabric applied to the
forearm 39
Fig. 34. Molded splint held in place while harden-
ing 40
I^ig- 35- Splint lined with non-absorbent cotton. ... 41
^^g- v36. Anterior and posterior splints secured by
strips of adhesive plaster 42
^^^' 37' Bandage covering the molded splints .... 42
Fig. 38. To and fro passage of the plaster of Paris
roller bandage 43
Fig- 39- ^folding splint for fracture of humerus. . . 44
Fig. 40. Molded splint for fracture of humerus
suspended to dry 45
Fig. 41. Molded shoulder cap, front view 46
Fig. 42. Molded shoulder cap, lateral view 47
Fig. 43. Applying sugar-tong splint forearm in
pronation 48
Fig. 44. Holding taut the extremities of the sugar-
tong split 49
VIIT.
LIST OF ILLUSTRATIONS
PAGE
Fig. 45. Muslin bandage passed around the sugar-
tong splint 50
Fig. 46. Braatz's spiral molded splint for Colles
fracture 51
Fig. 47. Posterior molded splint for fracture of one
or both bones of the forearm 52
Fig. 48. Plaster of Paris gutter splint for fracture
of one or both bones of the leg 53
Fig. 49. Application of plaster jacket in Sayre's
suspension 55
Fig. 50. Plaster of Paris jacket provided with hooks
for lacing 57
Fig. 51. Plaster of Paris corset with jury-mast in-
corporated 58
Fig. 52. Application of plaster of Paris corset in
horizontal position 59
Fig. 53. Application of plaster of Paris corset by
horizontal method in hammock 60
Fig. 54. Plaster of Paris coronet and corset united
by steel bands 62
Fig. 55. Lorenz plaster of Paris bed 63
Fig. 56. Plaster of Paris jacket with figure of eight
turns about the neck 64
Fig. ^y. Plaster of Paris collar 65
Fig. 58. Plaster of Paris coronet 66
Fig. 59. Application of hip spica in the horizontal
position 67
Fig. 60. Lorenz spica for unilateral congenital dis-
location 69
Fig. 61. Double spica for bilateral congenital dis-
location of the hip 70
Fig. 62. Wolflf's method of redressing club foot... 71
Figs. 63 and 64. Dental impression trays 73, 74
Fig. 65. Model of hypertrophied jaw 74
Fig. 66. Model of a syphilitic perforation 75
IX.
LIST OF ILLUSTRATIOXS
Fig.
67.
Fig.
68.
Fig.
69.
Fig.
70.
Fig.
71-
Fig.
72.
PAGE
Model of a cleft palate 76
Kingsley obturator 77
Kingsley obturator covering the cleft 78
Model of a fracture of the jaw 79
Model of a primitive articulation in plaster 80
Interdental splint with fenestra for feed-
ing 8i
X.
PLASTER OF PARIS AND HOW TO USE IT
CHAPTER I
THE PLASTER OF PARIS BANDAGE
Matkrials
The very widespread use of the plaster of Paris band-
age in hospital and dispensary practice for purposes of
fixation and immobilization of fractured bones and dis-
eased joints is in decided contrast to its limited use in
private practice. An inquiry into the reasons therefor finds
its best answer in the statement that the plaster of Paris
bandage found on the market does not usually come up
to the requirements. Therefore a description of what
constitutes a properly made plaster of Paris bandage is
of the first importance.
The plaster of Paris used in the making of the band-
age should be of the superior quality used by dentists, and
the quick-setting kind is to be preferred. It is sold packed
in tin cans to prevent deterioration (oxidation) by ab-
sorption of water from the air; and for a like reason it
must be stored in places free from moisture when once
the original package has been opened.
Any one of a number of diflFerent fabrics may be em-
ployed as a substratum in preparing the bandage, such as
gauzes, crinolin (gauze impregnated with starch), dex-
trine gauze and Hannel.
The use of plain gauze or muslin is undesirable because
the plaster sets very rapidly, and becomes too brittle. On
2 PLASTER OF PARIS ASD HOW TO USE IT
the other hand, a gauze too rich in starch or dextrine
will wholly prevent the plaster from setting. The mesh
of the gauze should be 28x32 threads to the square inch.
The best kind of gauze is white crinoline without cross-
bars.
Manufacture of the Bandage
The superior plaster of Paris bandage is made by hand,
for the reason that, made in this way, the right quantity
of plaster can be incorporated in the bandage. The crino-
Fig. I. Preparing plaster bandage by hand.
line is cut into strips of the widths desired, and loosely
rolled in ten-yard lengths. One yard at a time being un-
rolled, a handful of plaster of Paris is rubbed into the
gauze with the palmar surface of the fingers, so that ail
excess of plaster passes to either edge of the bandage.
(See Fig. i.) No more plaster should be rubbed into
the dextrine gauze than the meshes will hold, and as
each successive yard is incorporated with the necessary
quantity of plaster it is loosely rolled in such manner
that in the center of the bandage there is a hollow cyl-
inder of the thickness of the finger, and the coneentric
layers are easily i)i07'able on one another. This arrange-
ment permits the rai^id and uniform spread of the water
PLASTER OF PARIS AND HOW TO USE IT 3
through the bandage, and prevents parts of the bandage
from being insufficiently moistened. To guard against
unraveHng, a pin should be inserted in the last turn.
Storage
The completed bandages should be placed on end and
sealed in individual tins in the bottom of v^hich a small
quantity of plaster of Paris is placed, or, likewise ar-
ranged on end, they may be packed in bulk in large tin
containers. If the plaster cannot be stored in a dry
place, it is advisable to wrap each bandage in wax paper
or gutta percha tissue, newspaper also answers, and, in
any case, it is a wise precaution to seal the can with a
strip of adhesive plaster, passed about the overlapping
edge of the cover. The individual tins or tin containers
protect the bandages from moisture, and, furthermore,
permit them to be placed in ovens, as a preliminary to
using them, in order to drive off any moisture.
Bandages of Commerce
A very rigid plaster of Paris bandage has recently been
put on the market. It is made of exceedingly fine flexible
aluminum bronze zmre netting and is sold in widths of
one and one-half, two and one-half, three and one-half
and four inches, in four-yard lengths. It is applied in the
same manner as the regulation plaster bandage. The
disadvantages common to the plaster of Paris bandages
of the shops are that the fabric is not of the dextrine
order ; the mesh is too closely woven — the plaster lies on
the bandage instead of in the meshes — and as a conse-
quence, there is an excess of plaster; the bandages are,
as a rule, so tightly rolled that the water does not reach
the deeper layers. These are the bad features of the
machine-made bandage. It is manufactured by dragging
the strip of muslin through a compartment filled with
piaster of Paris, and winding it upon a windlass. (Fig.
2.)
PLASTER OF PARIS AND HOW TO USE IT
Fig. 2. Plaster of Paris cradle.
Molded Splints
A form of plaster dressing, well adapted to the making
of molded splints, can be obtained by dipping strands of
hemp jute (Beeley), flax or straw, of about the width of
the finger, in a cream of plaster of Paris. This is by far
the cheapest form of plaster of Paris dressing. Cotton,
impregnated with plaster of Paris and placed in seamless
sacks of tricot, constitutes another method of making
molded splints (Breiger). A modification of the Beeley
hemp splints consists in placing into a sheath of tricot or
the leg of a stocking, a bundle of thoroughly beaten hemp
strands, steeped in plaster cream. This sausage-shaped
mass is thoroughly kneaded and molded to the parts
(Turner). Other fabrics Hke sail-cloth, which contain
sizing material, are also useful for making molded splints;
and I have found the fabric known as "Deimel linen
mesh" suitable for making molded plaster of Paris splints.
Protection from Soiling
Before starting to apply the bandage, the surgeon and
his assistants should be properly gowned. In every in-
stance the forearms should be bared, so as to permit the
greatest freedom of motion in applying the bandage. To
protect the clothing from being soiled, a rubber apron
PLASTER Of PA fas AXD flOir TO USE IT 5
or gown should be worn {Fig. 3), or the latter may be
improvised from a bed -sheet. Either one should extend
to the collar, and it should be sufficiently long to cover
the feet, or a pair of rubbers should be slipped over the
shoes.
In private practice especially it is also necessary to pro-
tect the surroundings from soiling by the plaster of
Hg. $. Plaster baudage lifted frotii water, stiueea^edt and free end
opened. Manner of handinir U to sureeon. ( From W. M.
Brkkn^r's "Tiit SifRCiCAL Assistant. By courltsy of
the publishtr.)
Paris. The floor, tho patient's body, and the couch of
table on which the patient is placed should be covered
with muslin, gtmny sacks, bod sheets or a rubber sheet.
When these are not available, tar paper, newspaper^ or
ordinary wrapping paper will serve the purpose.
The Immediate Preparation of the Bandages for Use
I The number of bandages intended for nse should be
I removed from the tin container and stood upon end
6 PLASTER OP PARIS AM) HOW TO USE IT
within a foot of the vessel holding the water in which
they are to be immersed. The tin container, uncovered,
is to be within arm's reach, in case necessity arise to use
more bandages. The bandages to be used are to be
placed to the right and the container to the left. This
arrangement guards against particles of water being
spattered upon the bandages still in the container, ren-
dering them unfit for subsequent use.
Fig. 4. Freeing bandage of frayed edges. (From W. M. Brickner's
"The Surgical Assistant." By courtesy of the publisher.)
The vessel in which the bandages are to be immersed
should be deep enough to accommodate the widest band-
age vertically. But one bandage at a time should be im-
mersed. It is to be placed endwise in the vessel, which
contains water as hot as the hand will tolerate. The
bandage must be completely submerged, and it should
remain so until the bubbles cease to come off. This will
PLASTER OF PARIS AND HOW TO USE IT 7
take place most readily in the very loosely rolled band-
ages. The tightly roiled bandages obtained in the shops
should therefore be unrolled and rendered loose before
they are wet. When the bubbling has ceased, the bandage
is lifted out of the vessel, and squeezed with the hand,,
merely to free it of the excess of water. In some band-
ages the edge of the crinoline frays out, and becomes so
entangled as to hinder the free unrolling of the bandage.
To prevent this, the frayed out ends should' be plucked
from each side before starting to apply the bandage.
(Fig. 4.)
Chemical Adjuvants
To hasten the setting of the bandage, some manufac-
turers recommend the addition of salt or alum to the hot
water. This is not advantageous inasmuch as the band-
age often sets in the hand before it is unrolled. With
the home-made bandage prepared, as previously de-
scribed, with the best quick-setting plaster, the addition
of chemicals to the water is superfluous.
Protection of the Skin
The skin has to be protected from the plaster of Paris^
This may be accomplished in various ways. The area to
be encased in the plaster of Paris bandage may be wrap-
ped in cotton wool. The drawback to this is that the
cotton becomes ''caked'* and the bandage subsequently
loosens. Better than this is the use*of a flannel bandage,,
or the *'ideal bandage,'* which is to be applied smoothly,,
without wrinkles and without "reverses," for these are
apt to exert pressure on the soft parts beneath when the
weight of the plaster is brought to bear. An elegant in-
vestment of the skin is afforded by the use of seamless
tricot hose, which can be had in various widths and is
applicable to the trunk or extremities. For the latter a
comfortably fitting sock, stocking, undershirt sleeve or
Y
8 PLASTER OF PARIS ASD HOW TO USE FT
drawer leg may be used. When the plaster bandage is
applied to serve as a cast, the limb need merely be
anointed with vaseline.
Application and Precautions
No undue traction should be made in applying the suc-
cessive turns of the bandage. The use of any other than
a light hand, when unrolling the bandage on to the mem-
ber, will be followed by such constriction of the limb
and interference with circulation, with the setting of the
plaster, that its prompt removal will probably be re-
quired.
In fractures, if the swelling be very marked, if there
be evidence that the extravasation has not attained its
maximum, the limb should be elevated and subjected to
the compression of a rubber bandage, and this should be
followed by gentle massage, before the plaster bandage is
applied. On the other hand, it should be borne in mind
that usually several hours elapse after the injury before
the surgeon has been called and has made preparations
to apply the plaster, and generally, therefore, there need
be no dread of an increased swelling beneath the bandage.
Indeed, the best means of limiting the swelling after a
fracture is the prompt application of a plaster of Paris
bandage. If there be any concern that the plaster band-
age has' set too tight, or will do so, this may be remedied
in the following manner: While the plaster is yet soft,
cut through the entire length of the bandage with a pen-
knife, and with the bandage shears also divide the band-
age, cotton or tricot, underneath. The subsequent con-
traction of the plaster in the act of hardening will cause
a further widening in the furrow made with the penknife,
and thus relieve the pressure existing. In fact, where
the circumstances are such that the bandage cannot be
inspected within the first twenty-four hours after its
application, it should always be the practice to divide the
PLASTER OF PARIS AND HOW TO USE IT 9
plaster as described, in order to forestall any possible
unpleasant developments.
To guard against a loosening of the plaster of Paris
bandage, as the furrow widens, strips of adhesive plaster
may be drawn across the gap to limit it, and then a stout
muslin bandage applied over the whole plaster dressing.
Some days later, when the bandage has adjusted itself to
the underlying parts, and the swelling has subsided, the
adhesive strips may be drawn tight enough to obliterate
the furrow and make the bandage fit snugly.
Marked bony prominences that have to be covered by
the plaster should be protected with a layer of cotton be-
fore applying the flannel bandage or tricot hose. As each
successive turn of the plaster bandage is applied it should
be smoothed, always in the same direction, by friction of
the hand, moistened occasionally with water. ^If the \/
bandage be properly made, at no time is it necessary to /\
rub in any loose dry plaster, or any paste of plaster that
settles in the vessel. \ In fact, this excess of plaster, when
it sets, adds unnecessary weight to the bandage, and lying
between the layers of gauze, as it does, and not incor-
porated with the fibre, it renders the dressing brittle.
The outer layers of the plaster bandage are apt to chip,
and these loosened particles irritate the skin and soil the
garments and surroundings. ( To obviate this, the finished
plaster of Paris dressing should be covered the day after
it is applied with a single layer of dextrine bandage,
which is moistened and made limp before it is applied,
but soon becomes dry and hard again, i
The plaster of Paris bandage may be applied to a mem-
ber in continuity or in sections. In the former method,
the bandages are wound spirally up and down the length
of the limb without reverses until each roll of bandage is
exhausted, and a number of bandages is used to cover
the same ground until all parts are sufficiently covered.
In the latter method, the limb is divided oflf into segments
and each segment is separately invested with one or two
10 PLASTER or PARIS AXD HOW TO USE TT
bandages, according to requirements : each section of
plaster overlapping the adjoining one. The former
method provides a stronger dressing.
The finished bandage should be exposed to the air to
effect a thorough hardening. When a hot air apparatus
is at hand the whole member may be baked for one-half
hour.
The upper and lower limits of the plaster bandage must
not extend beyond the bandage enveloping the skin. An
Fig. 5, Illustrating the cuff of cotton at the upper and lower limits of
the plaster of I'aris bandage.
elegant finish may be given to the edges of a i)laster dress-
ing by turning over its ends, in cuff-like fashion, the ends
of the flannel bandage. ^This device must be borne in
mind while the plaster is being applied, so that the final
turns of plaster at either end may securely hold in place
the retroverted fold of flannel bandage. Equally efiicient
in preventing the ends of plaster from impinging on the
skin is a cuff of cotton held in the grasp of the last turns
of plaster at either end. (Fig. 5.) y
When the flexure of a joint is encroached upon by the
plaster, a crescentic section may have to be removed from
the latter in order to allow free motion of the joint. This
had better be done while the dressing is in the plastic
state. Again, with the bandage in the plastic state, it can
be molded by the pressure of the finger and hands with
massage-like motions, to conform it to the contour
of the limb. To bring about an adaptation this molding
is far superior to, and less dangerous than, the employ-
ment of traction on the plaster bandage.
Fip. 7. niiistrntiriii rff metliod nf cliviiHii^ i>]a5ter cast wiUi ESij^li i»aws
ulacctl under tlif tiiimlagrs.
to pn>tr;Kleas a ^uide where to start cutting^ tlie bandage,
Tlie iiK^tal heneath i>i to ^iiard the skin aj^^^ainst hcinf^; ciii^
12 PLASTER OF PARIS AND HOW TO USE IT
by strokes of the knife. It has also been recommended to
place a Gigli saw (Figs. 7 and 8) on the limb, before ap-
plying the plaster. To the protruding ends of the saw
metal handles are to be attached, and with the aid of these
the wire is set in motion and the plaster divided from be-
neath. Even though this saw is constructed of aluminum
bronze it is liable to corrosion and does not work freely.
Fig. 8. Plaster of Paris cast removed in lateral halves, having been cut
through front and back with mitre or (iigli saw.
If it is the intention to utilize the plaster of Paris band-
age again, care must be taken to preserve its integrity.
This can be best accomplished by cutting a furrow ( Fig.
9) into the i)laster in its entire length with a penknife, or,
more expeditiously performed, with a luifrc sazc. (Fig.
10.) The fabric beneath the plaster constitutes an im-
pediment to the free motion of the saw and therefore
gives indication when the plaster is divided, and thus
I
Fig, 9. ^howinw the groovers cm m the pbstor cast v\hU ihc mitre saw,
prevents injury to the soft parts beneath. When the
penknife is nsed. the dropping of acetic acid (or vinegar)
on the plaster, along the path of the knife, will lighten the
otherwise irksome task.
¥ig. 10, Mitre saw.
All complicated devices of the circular saw are useless,
as the mechanism becomes blocked with particles of
plaster.
A very effective instrument for cntting a fnrrow in
the plaster bandage are Stilles' shears. {Fig. 11.) The
F11?, ft, Stilles shears.
14 PLASTER OF PARIS AXD HO IV TO USE IT
section of bandage removed falls out of the window of
the cutting blade. These shears are constructed like
some of the bone cutting forceps, but they are not at all
serviceable in passing about an angle like the ankle joint.
Fig. \2. Ma
of removing tlic cast from the limb.
After the plaster is divided at every level, the bandage
beneath is divided with shears. Now the whole cast may
be lifted from the limb, much in the manner that a hoop
is sprung from a barrel (Fig. 12), or by a motion similar
to the opening of calipers. The flannel bandage is adher-
ent to the plaster and comes away with it.
Fig 13. Illustrating manner of reapi)lying the cast with adhesive straps.
Replacement of the Cast
Eventually the cast may be lined with absorbent cotton,
or the limb invested with another flannel bandage before
replacing the cast. Straps of adhesive plaster are applied
circularly over the plaster cast (Fig. 13) and the whole
recovered with a moistened dextrine bandage.
PLASTER OF PARIS AND HOW TO USE IT IS
Toilet After Bandage is Completed
Such piaster of Paris as may have been spattered on
clothing, carpets or fabrics had best be allowed to dry
thoroughly before an attempt is made to remove it. The
spots on furniture or wood-work had best be removed
while moist, or if dry, they should be moistened. If not
much time has been consumed in applying the plaster of
Paris bandage, and the plaster on the surgeon's hands is
still moist, it can be readily washed off in warm running
water, (if it be dry, however, friction of the hands with
granulated sugar will speedily dissolve the plaster. Fric-
tion with salt will effect a speedy removal by rendering
the plaster more brittle, and the same may be said of
ablutions with bichloride of mercury. )
Disposal of Refuse
The discarded portions of plaster bandage and excess
of loose plaster should be cast, away with household
refuse. The water used for immersing the bandages
should be decanted from the plaster paste in the bottom
of the vessel and emptied into a sink or privy, which is
then to be flushed with hot water, preferably from the tap.
Under no circumstances should the paste from the vessel
be emptied into the waste-pipe, for it is likely to choke
it up. The paste, if immediately attended to, may be
loosened by shaking the vessel or by imparting a smart
blow to it. If this does not suffice, or if the vessel be
porcelain, the adherent masses may be lifted or scraped
off with a piece of wood or a knife. The addition of
water, hot preferably, will aid in loosening the plaster.
The whole mass is to be thrown away with other house-
hold refuse or to be incinerated in a furnace.
i6 PLASTER OF PARIS AND HOW TO USE IT
CHAPTER II
THE APPLICATION OF THE PLASTER OF
PARIS BANDAGE TO INDIVIDUAL
FRACTURES
FrACTUKKS wSuiTABLK FOR PlASTER
There is hardly a fracture of any bone in the body
requiring immobilization, for which the use of the plaster
bandage has not been advocated. Enthusiasts, indeed^
would have us use plaster bandages for all fractures. An
enumeration of the fractures for which the plaster band-
age is neither desirable nor practical will best show its
limitations. These are: fractures of the skull (for ob-
vious reasons) ; of the wrist (Colles) ; of the clavicle;
of the ribs ; of the shaft of the femur in infancy, in all
cases, and in adolescence, in most cases. In all other
fractures the use of a plaster of Paris cast is in place.
In fractures of the forearm and arm in infants, because
of the small dimensions of the parts, plaster of Paris is
always to be preferred to splints. The X-rays readily
penetrate the plaster, so no objection can be offered to
its use on this score. Except when applied to the lower
extremities, its weight can be kept down to that of any
variety of splint.
General Considerations
The immediate use of plaster of Paris for fractures
does not imply its instant application. Usually, several
hours elapse before the bandage is applied ; by which time
the swelling about the fracture will have attained its
PLASTER OF PARIS AND HOW TO USE IT 17
maximum. If it is desired to reduce this swelling, or
keep it at its minimum, elevation, massage, the use of a
flannel or rubber bandage, preliminary to the application
of the plaster bandage, will accomplish this. In the use
of the plaster of Paris bandage, perhaps more so than
with other sorts of splints, an anesthetic is often required,
and for the following reason : If the patient be at all
restless while the deformity is being corrected and align-
ment maintained, it is very likely that the plaster band-
age will be put on with undue pressure ; and violent mo-
tions of the patient may crack the quickly-setting plaster.
If swelling of the fingers or toes or of the extremities
distal to the bandage should supervene, the immediate
removal of the bandage is by no means always nccessar}-.
Before taking this step we should be guided by the color,
warmth, and amount of pain. If the extremity be cold,
blue, anesthetic, or extremely painful, and a pulse cannot
be felt, there should be no hesitancy in the instant loosen-
ing of the cast by splitting it. On the other hand, if, in
spite of the swelling, the limb be warm, and not unduly
red (inflammation excluded), and the accompanying pain
and throbbing be a source of great discomfort, it is desir-
able to resort to the expedient of elevating the entire
member by suspension or by placing it upon cushions,
and to secure absolute rest by the administration of an
opiate. If, after recourse to these measures for twenty-
four hours at the utmost, the pain ])ersists or is worse,
and especially if the warmth of the extremities gives
place to cold, the cast must be split forthwith. Great
caution must be exercised when these evidences of cir-
culatory disturbances — swelling, edema, lividity — mani-
fest themselves ; for neglect to visit the patient frecjuently
may cost him his limb and the surgeon his reputation.
It need not necessarily follow that the limb becomes gan-
grenous — a fate just as bad awaits a limb encased in
plaster of Paris, when the patient complains of pares-
thesia and anesthesia. The undue pressure of the plaster
i8 PLASTER OF PARIS ASD HOW TO USE PT
of Paris, responsible for these symptoms, will, if not re-
moved, cause ischemic paralysis, terminating in perma-
nent contractures. A mere splitting of the cast in its
entire length will put an end to all the untoward symp-
toms just mentioned.
Lender the most favorable circumstances, in the course
of a week or two, with the subsidence of the swelling
the cast may become so loose that it is necessary to re-
move it, either to pad its interior with non-absorbent cot-
ton, or to make a thicker investment of the limb ; after
either of which the cast may be replaced. An undue
amount of perspiration with severe itching, or the pres-
ence of a solid substance which had accidentally made
its way beneath the plaster, also demands the removal of
the cast.
Posture
When applying a plaster bandage for fracture, whether
to upper or lower extremity, the body must be in a re-
<:umbent position. The arm, leg or thigh to be bandaged
should project beyond the edge of the table and be sup-
ported by an assistant. It is impossible to apply a plaster
bandage to the extremities of an infant struggling in
the arms of its mother or nurse ; nor is the sitting posture
in an adult conducive to that relaxation of the muscles
necessary for the proper application of the bandage to
the extremities.
PLASTER Of PARIS AND HOiV TO USE IT ig^
CHAPTER 111
FRACTURES OF THE UPPER EXTREMITY
FiiACTLTRK OF Om-: f.»R I'trni Pioxi^:^ nr Foukarm
The patient shoultl be placed on hi? back, with the body
close to the f^dgv of the table, and both forearm and arm
extending beyond the edge, supported by an assistant.
Kijf, 14. Arrlicntitm of ii]n?^l*-r nf Pht\^ Mndaiff far frflciiire of thi?
fnrcann.
{Fl^. 14J rhc deformity is reduced by manipulating'
the frag-ments* makintr extension and flexion in tho
antero-posterior or lateral direction, associated with su-
pination or rotation. The proper alignment accomplished
(an anesthetic to he administered if necessary), the as-
sistant grasps the patient's hand, as in fhe act of hand-
20 PLASTER OF PARIS AXD HOW TO USE IT
shaking, making traction and executing counter-exten-
sion if necessary, or merely supporting the forearm —
whichever is necessary to maintain the aHgnment. The
plaster bandage should extend from the wrist to the flex-
ure of the elbow. The flannel bandage immediately in-
vesting the forearm, however, should extend to the heads
of the metacarpal bones, thus enveloping the hand. The
fingers are left free. Thus we prevent edema of the dor-
sum of the hand, and by the color of the fingers we may
judge of the circulation. If the fracture of the radius
or ulna, or of both bones, be in the upper third, it may be
necessary to flex the forearm on the arm. In that event
the plaster of Paris bandage will include the elbow, and
must be carried up the arm as far as the fold of the
pectoral muscle, to secure the right purchase. If the
bandage on the arm extends only a little above the level
of the elbow joint or half way up the arm, the weight
of the plaster bandage on the forearm, by breaking up
the flexion, will cause the upper part of the bandage to
press into the soft parts. The flexure of the elbow
should be well cleansed, dried and dusted freely with
bismuth subgallate (dermatol), before the bandaging,
to prevent chafing (dermatitis).
Fracture of Shaft of Humerus
In fracture of the shaft of the humerus in its middle
or lower third, when we are not concerned with the ab-
duction of the upper fragment, a plaster of Paris dressing
is suitable. The patient occupies a sitting posture. The
reduction having been eflFected, the limb is brought into
adduction, so that the chest wall forms an internal splint.
A thin layer of non-absorbent cotton, well ducted on
both sides with dermatol, being interposed between the
arm and the chest wall, the arm is held in place by cir-
cular turns of a muslin bandage, which pass obliquely
over the shoulder, enveloping it. The forearm is left
free, so that by its weight, even though supported by a
PLASTER OF PARIS AND HOW TO USE IT 21
sling about the wrist, it exerts extension on the lower
fragment. In the same manner, the plaster of Paris
bandage envelopes the arm and shoulder, securing them
to the chest. A layer of cotton wool should be placed
over the clavicle and shoulder, to prevent pressure by
the plaster bandage. For infants but one bandage, five
yards in length, is necessary ; for adults, two will suffice.
The forearm should be snugly wound with a flannel band-
age, to prevent the development of edema.
Fracture of the Elbow Joint
Experience has taught that the plaster dressing is not
well suited to fracture of the elbow joint, other dressings
being better adapted. When, however, the plaster band-
age is chosen, the following steps in its application should
be observed. The patient occupies a recumbent position,
and the arm, projecting beyond the edge of the table, is
supported by an assistant. The forearm is flexed as
acutely as possible. In the flexure of the elbow joint,
freely dusted with dermatol, a thin layer of cotton batting
is placed, and the bony prominences are also enveloped in
non-absorbent cotton. The arm and forearm, from the
axillary fold to the wrist, are invested with a flannel band-
age, and over this, in turn, a plaster of Paris bandage is
placed. (Fig. 15.) The plaster bandage does not cover
the upper and lower limits of the flannel bandage.
These are turned back so as to form a cuff at either end,
a single turn of the plaster bandage being sufficient to
secure them. This cuff prevents the edge of the plaster
from pressing into the skin, and guards against unravel-
ing of the flannel bandage.
CoLLEs' Fracture
In all respects the plaster bandage is to be applied here
like the cast described for fracture of one or both bones
22 PLASTER Of PJRfS JXP IHUr TO USE IT
of tlic foreanii, save that the wrif^t is inchKleci, and the
baiirla^u is carried down tn the licads of the metacarpal
bones.
Caution: It is this imniobihzation of the wrist, how-
ever, which constitntes a g^reat drawback la the nse of
tilaster of Paris in this fracture, iov wliich many other
devices are far better suited.
FIk- 15. Plaster east for lower third of the arm, ilie elbow, or the Mjipcr
(liird iif tVie foreurm.
I
FuACTUME OF TUt-: Thumb
This is the one finger for which, if it is fractured in
any of its parts, a plaster of Paris dressing is suitable.
Whether the first or second phalanx or the metacarpal
bone, is fractured, the thimib, in the extended and ab-
ducted position, is covered with a flannel bandage spica,
passing in fignre-of-eight turns about the ^vrist* or a
cotton glove, with the other fingers cut ofT^ is slipped
PLASTER Of PJRiS AND HO IV TO USE IT 2j
over the hand. Either in vestment is covered with ^
"spica polUcis** of plaster of PariSj hichidiiig the wrist
and terminating an inch above it. (Fig. i6,) As in alf
other casts, the edge of the plasttr handaii^e is covered
with the last torn of the flannd handafje.
Ffg. t(j. Caai for fracture of the tliumb ur carihal botics. Dorsal view,
Fractl're of TitH Metacaiu^al and Carpal Boxes
If the fracture be in the shaft, or near or in the base
of the metacarpal bones, or in a carpal bone, the hand^
exclusive of the fingers but inclusive of the w rist and two
inches of the forcann, is invested with a Hannel i)andage,
and this in turn, is covered with a jilaster of Paris band-
age two inches in wndtlh (Fig, 17.)
Fig, 17. Cast fnr fTaclmr v( \hv ilmiiib nr carpal bnnes* Talniar view
showifi« cuffs rjf cotton at each end.
24 PLASTER OF PARIS AND HOW TO USE IT
Time Limit for Removal of Plaster Casts in Frac-
tures OF Upper Extremity
While no general rule can be formulated as to when
the cast should be wholly set aside in each of the frac-
tures considered, it should be the practice at the end of
the second week to remove the cast and inspect the site
of fracture. This is done to ascertain, not so much the
extent of union as judged by the wanton practice of
manipulation to elicit mobility, but rather to note whether
the alignment is the best possible. For neither a plaster
of Paris cast nor any other splint is designed to correct
any deformity, but only to hold the correctly placed
fragments in situ.
When the X-rays are available, and by their use it is
clearly seen, perhaps on the fluoroscopic screen, but pref-
erably in radiograms, that the apposition of the frag-
ments is all that could be desired, we may forego the
removal of the cast for the purpose of inspection.
PLASTER OF PARIS AND HOW TO USE IT 25
CHAPTER IV
FRACTURES OF THE LOWER EXTREMITIES
General Rule
Every cast applied for fracture of the hip, thigh, knee,
or leg should include the foot in a right-angled position.
Failure to do this will cause drop-foot (talipes equinus),
which constitutes a hindrance to walking during the time
that the cast is in place, and delays walking after its re-
moval. In neglected instances, indeed, this drop-foot
requires correction and the application of a plaster cast
to maintain the proper position.
Fracture at the Hip Joint
The use of a plaster cast in fractures of the senile hip
is indicated only if it is possible to have the patient walk
about on crutches. Other devices are more effective, but
at times not applicable, because they necessitate the pa-
tient assuming a recumbent position for many weeks,
which is apt to cause hypostatic congestion of the lungs.
The most effective plaster dressing is that which includes
the knee and ankle, enveloping the hip in a spica, the
upper limits of which include the ribs below the mam-
mary level.
Plaster of Paris Hip Spica
The patient occupies the recumbent posture, on a
kitchen table or a board resting on two horses. The
pelvis must be well down to the edge of the table, the
sound limb hanging over the edge and resting with its
foot on some support. The affected limb is held by an
assistant, who exerts extension. To prevent the displace-
ment of the body by the traction efforts, the lower end
26 PLASTER 01' PARIS AMJ HOW TO USE TT
of the table may be raised. In addition, a sling made of a
twisted bed sheet, is passed beneath the crutch (peri-
neum) and its ends secured to one of the further legs of
the table, or held by another assistant, to exert counter
extension. For that part of the dressing which invests
the lower part of the thigh, the knee, leg and ankle, the
pelvis may rest flat on the table, but while the turns of
the spica are applied, the pelvis must be elevated, the
shoulders remaining in contact with the table. This can
be accomplished in a variety of ways — by an apparatus
such as a hip-rest or by improvised devices. Of the
former, the one here illustrated, made of a band of iron
bent as shown (Fig. i8), and screwed to a plank, is
Fig. 1 8. Metal hip rest, screwed to board.
pushed under the pelvis. The blade supporting the pelvis
is covered in by the turns of the plaster bandages, but it
can be easily withdrawn after the plaster has set. Where
no hip rest is at hand a sling of stout muslin playing
about a pulley secured overhead, may be used to raise
the pelvis, the loop of the sling becoming incorporated in
the bandage. In other instances the pelvis must be sup-
ported by hands, or on the superimposed fists of an
assistant (Fig. 19), or an agate ware basin reversed.
These preliminaries effected, the bony prominences of
the spines and crest of each ilium are covered with cotton
batting or pads of piano f^lt. A flannel bandage now
invests the foot, leg, thigh, hip, waist and lower thorax.
PLASTER OF PARIS AND HOW TO USE IT 27
^\\\\^
Fig. 19. Pelvis raised on superimposed fists of assistant.
Over this the plaster of Paris bandage is applied. (Fig.
20.) A narrow, strip of piano felt is desirable about the
Fig. 20. Plaster spica of hip.
28 PLASTER OF PARIS AND HOW TO USE IT
waist to fill out the hollow, for in this situation the spica
is very likely to crack. This accident may also be
guarded against by increasing the turns of the bandage
at that level. The perineum must be particularly guarded
by proper padding, and if the turns of the bandage hug
it too closely a crescentic segment must eventually be
removed to avoid the production of a pressure sore. This
part, also, must be well dusted with dermatol or talcum,
and either one of these powders is to be blown in under
the upper margin and about the pubis, to prevent irrita-
tion of the skin. That part of the cast in the vicinity
of the genitals may be coated with shellac so that urine
or vaginal secretions does not penetrate the cast, render-
ing it foul and brittle.
In children, fracture of the neck of the femur is as-
sociated with adduction of the thigh. Where this diag-
nosis obtains, the extremity should be put up in a posi-
tion of marked abduction.
In children, a plaster of Paris spica may also be applied
by suspending the patient in a Sayre's suspension appa-
ratus.
Fractukks of the Femur (Shaft)
The position occupied by the patient is the same as de-
scribed for fractures at the hip. The cast should extend
from the gluteal fold, and should include the foot at right
angles. This form of cast is applicable to fractures in-
volving the Knee Joint and for Fractures in the Up-
per Half of the Leg. (Fig. 21.)
^^j^jjiA£fi*SH^>^
Fig. 21. Plaster cast for fracture of upper half of leg. Note right-
angled position of foot, and extent of cast.
PLASTER OF PARIS AND HOW TO USE IT 29
Fractures of the Lower Half of the Tibia and at
THE Ankle Joint
These fractures are so severe and are accompanied
with such deformity that they necessitate a narcosis to
make the proper correction. Furthermore, if unattended
by a wound they are the fractures of the lower extremity
best suited for the ambulatory cast.
The patient occupies the supine position. The flannel
bandage or tricot base (Fig. 22) extends from the con-
dyles of the tibia, and the lower margin of the patella,
and includes the foot — which is held at right angles by
an assistant. (Fig. 23.) The crest of the tibia is cov-
ered with cotton
wool to protect it
from pressure.
When there is no as-
sistant to hold the
foot, a muslin band-
Fig. 22. Illustrating tricot hose investment in age sHug is paSSCd
fracture of the leg. i_ j. ^i . ^
about the great toe
(Fig. 24) and either held taut by the patient, if he be
conscious, so as to bring the foot at right angles to the
leg, or the strings of the bandage are fastened to the
upper end of the table. About the condyles the plaster
of Paris bandage is to be heavily applied so as to form a
cuflF.
The cast which is most desirable for fractures at the
ankle joint differs from the preceding only in the very
important particular, the position of the foot.
This variety of fracture is most commonly followed
by flat-foot. To obviate this it will always be necessary
to have the foot well inverted (varus) and at a right
angle to the shaft of the tibia. Thus the patient is made
to walk on the outer side of his foot. When it is intended
that the cast should be an ambulatory one, a cuff of plas-
30 PLASTER Of PARIS AM) HO It' TO USE IT
ter should closely hii^ the tibia and an extra iinnibcr of
turns of plaster of Taris should be [massed about the
Fig, --J. ^laiutt^i'
;,IN'^-^'^L:'
I'i jsbster
I
lower fourth of the \v^, some of them embraciiig the
ankle.
The upper limit of this plaster cast, while it UTUSt
closely embrace the condyles, should not encroach upon
the popliteal space where it would limit flexion at the
knee joint. This is avoidable by cuttinj:^ out a crescentic
strip of plaster with the penknife while the bandage is
yet in the plastic state. Other points of pressure in this
cast are generally encountered on the inner and outer
aspects of the foot. These are avoided by not carrying^
the turns of the plaster bandag^e so. far forward as to
impinge on the toes. Tf these pressure points do give
trouble, g^reater relief will be afforded by splitting the
bandage on either its inner or its outer side^ than by
ctitting off any bandage in lYt^ circular direction.
PLASTER OF PARIS AND HO IV TO USE IT 31
Fractures of the Foot
A fracture of any of the bones of the foot may be very
well treated by a plaster of Paris bandage, including the
Fig. 24. Foot being drawn up at a right angle by a strip of bandage
held by i)atient.
ankle and terminating over the lower third of the leg,
below the level of the calf.
Caution: The dorsum of the foot should be well pro-
tected from pressure by a padding of non-absorbent cot-
ton. When the metatarsal bones are fractured, a pad of
piano felt should be placed on the plantar surface as an
effort to preserve the transverse arch.
Fenestrated Plaster of Paris Dressing for Com-
pound Fractures
This term applies to an ordinary plaster of Paris
bandage in a part of which a window is cut to permit of
treating the underlying wound. (Fig. 25.) The open-
ing in the cast should always be larger than the wound.
32 PLASTER OF PARIS AND HOW TO USE IT
Methods of Fenestration
The window can be made in a variety of ways.
A. The wound, covered with appropriate dressing,
may be included in the plaster of Paris dressing. Its
location having been noted by measurement, a window
corresponding to its dimensions is then cut from the
plaster before it has set. The rough edges of the plaster
bandage can be smoothed and still further protected
from the discharge of the wound by investing the edges
with adhesive plaster, or with gutta percha tissue made
to adhere with chloroform.
B. The wound, duly protected, is covered with a
measuring glass, a graduate or a tumbler of convenient
size, the turns of the. plaster of Paris bandage passing
about the glass.
The Ambulatory Plaster of Paris Cast
The treatment of fractures of the leg and particularly
those of the ankle,
where there is no axial
displacement of the
fragments, demanding
extension, are best
suited for the "ambu- Fig. 25. showing piaster of Paris splint
, , , ,, with two fenestrae.
latory cast.
It is the practice of some surgeons to have the upper
limits of the cast at the condyles of the tibia, others
would include the knee joint.
The indications for the choice of either may be set
down as follows: Where the fracture is limited to the
ankle joint a cast extending to, and embracing the con-
dyles, is sufficient. All fractures above the middle of the
leg call for immobilization of the knee also. Under these
circumstances the cast should be carried up to the gluteal
fold.
PLASTER OF PARIS AND HO IV TO USE IT 33
Experience has shown that no metal or wood strips
need be incorporated in the plaster of Paris dressing.
The ambulatory plaster of Paris splint differs from the
ordinary plaster dressing applied for a like fracture, in
the extent of the immobilization, in the greater number
of the plaster of Paris bandages used, and in the increase
in thickness of the plaster of Paris bandage by multiply-
ing the turns at certain levels. The one situation favored
by increase in thickness to prevent cracking, is just above
the ankle joint. The upper limit of the plaster about the
condyles of the tibia is also increased in thickness so that
the weight of the body transmitted to the cast will not,
in being transferred to the knee and thigh, cause the cast
to cut into the soft parts, as would be the case with a
thin edge of plaster. The ambulatory plaster splint is
practicable in a fracture of the ankle or leg without a
stirrup, by virtue of the mechanical fact that in a pillar,
the stress and strain are distributed on the surface.
Hence the column of plaster about the fractured leg car-
ries, in greater part, the superimposed weight of the body.
To give some elasticity to the rigid plaster beneath the
plantar surface of the foot, some authorities advocate the
insertion of a layer of felt.
The use of the ambulatory plaster of Paris splint does
not imply that walking with a fractured limb will be
possible at once. Only after several days, most common-
ly at the end of the first week, the patient can make eflforts
at standing and gradually, as he gains confidence, the
limb can be used to walk with. In course of time the
plaster of Paris on the sole of the foot softens. This may
be unheeded, for with the free use of the limb the foot is
protected with either a felt slipper or an arctic.
Fracture of the Patella
In very exceptional instances, where there is so scant
a separation of the fragments that they can be approxi-
34 PLASTER OF PARIS AND HOW TO USE IT
mated, as estimated by crepitus or the use of X-rays, the
plaster cast surpasses all other forms of treatment.
The chief point to be considered in its application, is
that the turns of the bandage must fit snugly about the
upper and lower limits of the patella. This can be ac-
complished best by forcing the bandage down upon the
patella while it is in the plastic state. Previous to apply-
ing the cast, approximation may be facilitated by passing
adhesive straps obliquely about the upper and lower
limits of the patella. Subsequent to the application of
the plaster of Paris dressing, a radiograph may be taken,
to ascertain the relation of the fragments. Inasmuch
as it is to be the purpose to have the patient to walk
about, the plaster of Paris cast should include the foot
in a right angled position.
If the plaster cast be effective in maintaining the frag-
ments, it may be removed after the lapse of two weeks,
to permit of daily massage, and replaced each time.
Fracture of the Of-ecranon Process
This is referred to here for the application of plaster of
Paris for this fracture corresponds in all essentials with
its application for fracture of the patella, just described.
Compound Plaster of Paris Splints
Whenever additional material is incorporated among
the layers of a plaster of Paris bandage, it is termed a
''compound plaster of Paris bandage." These materials
are incorporated to give additional strength to the band-
age and incidentally to reduce its weight.
Strips of veneering
(Figs. 26-28), tin and
iron, wire netting and
gutta percha are the ma-
terials most commonly
employed. The metals
are least desirable as they ^'^- ^^stiSgihen TheTas"^ ^*"^' *°
PLASTER OF PARIS AND HOW TO USE IT 35
are likely to become rusty, and by this corrosion, break
and penetrate the bandage.
In dressing after re-
sections of the elbow
and knee, these com-
pound plaster of Paris
splints find their great-
est usefulness. (Figs.
Fig. 27. Veneering strips spirally wound
about the cast.
26, 27, 28.)
Fig. 28. Veneering strips placed the length of the arm.
Segmented Spltxts
When it is desirable to have access to the wounds of
joints (or to wounds
extending over a
large part of the cir-
cumference of an ex-
tremity), so that they
may be approached I^g. 29. Bridging strips of metal permit-
from all sides, the ''"^ •""'•°" ""^ inspection of the joint.
joint (or other surface), is bridged over with bands of
metal, or with wire, which are incorporated in the turns
36 PLASTER OF PARIS AND HOW TO USE IT
of the segments of plaster above and below the joint, as
shown in figures 29 and 30. A sufficient curvature is
given to the strips so as to permit the joint to have some
range of motion eventually.
Suspended Splints
A strand of wire with hooks may be incorporated in
any variety of plaster
splint. These hooks
facilitate the suspen-
sion of the limb, as
may be necessary in
inflammatory c o n d i-
tions. (Figs. 30 and
A fenestrated splint may also have wire and booklets
incorporated in it to permit of its suspension. (Fig. 32.)
Fig. 30. Wire worked into the two sec-
tions of the plaster cast to facilitate
suspension of the limb.
Fig. 31. (a) Molded splint with wire hooks for
suspension; (b) the wire itself.
Heated Splints (Perthes)
In certain inflammatory conditions of the joints, nota-
bly in gonorrheal arthritis, in addition to the immobiliza-
tion effected by plaster of Paris, it may be desirable to
supply heat to the parts. When this is desired, there may
PLASTER OF PARIS AND HOW TO USE IT 37
Fig. 32. Fenestrated plaster splint with wire and booklets for suspension
be wound about the cast coils of rubber tubing, or nar-
row tubing of lead or of flexible tin. Through this tub-
ing very hot water is allowed to pass, and is carried off
into a pail.
40 PLASTER OF PARIS AX /J liOH' TO USE IT
on the several superimposed layers of gauze, to saturate
them. They are theu applied to the limb and molded in
the same manner as described in the first method.
Again, the plaster of Paris roller bandage, having first
been made plastic by imniersion, may be cut in lengths to
correspond tn measurements uf the extremity. Several
r
l"i|r, J4. Aloldtd suliiit hdtl in jtlact; while hardening.
such lengths are superimposed and then molded on the
limb as described.
Finally, the moistened plaster bandage may be directly
molded on the limb by playing the bandage to and fro
upon it, each end of the bandage being held by an assist-
ant, who grasps the successive turns as they are superim-
posed (Figs. 38, 39, 40), the surgeon at the same time
stroking the bandage to make it adhere tn the deeper
PLASTER OP^ PARIS AXD HO IV TO USE IT 41
layer. The subsequent steps are identical with those
mentioned above.
The Bavarian Splint
This variety of molded splints is made as follows:
Two pieces of canton flannel, shaped to conform to the
circumference of the fractured member, are sewn together
^'i^' J5i- Sl'lint lined with nuniibsurbent CDtton.
thwise through their middle, in single or double line
of stitches, the seam always arranged to occupy the pos-
terior aspect of the limb. One-lialf of the inner layer of
flannel is then passed about the Hmb and secured, by sev-
eral stitches or by adhesive plaster, to the underlying
dressing (bandage). Plaster of Paris paste is then ap-
plied, and thoroughly rubbed into this layer of flannel.
Before the phister has drier! the outer layer of flannel
42 PLASTER Oh PARIS iXf> HO IP 7n USfi IT
Fig. 36^ Aiilriifir ami fpusieriuf bSJiliniiJ Jitcuied by strips nf adiiesivfr
Fig. Z7- Till! bandaj^e covering I lit; splints.
rLJSTER Of FJKIS JXi) HOW TO iSL IT 4J
on the sami.' side, is superimposed. The two flannel layers
on tlie Qtlier side are then similarly manipulatecL When
both halves have set completely, they may be cut down in
front, and Innied to either side, the seam posteriorly
acting as a hin^e, to permit of an inspection of the parts,
after which the^- are tnmed hack ao"ain and secnrelv held
Vijl' jB* Tm ail J IT(P iia^^^Kc of the iiia^lcr of l^arit. rotk-r Lnili^i,
in place w^ith several strijis of adhesive jjUistcr. over which
tnrns of a nnislin bandai^e are passed.
Tnii U\:m\' SnjxT
This is another form of molded plaster of f'aris splint
A number of strands of hemp are beaten, then dipped
into a paste of plaster of Paris and spread out over the
limb, previously anointed with vaselin. Addititmal plaster
of Paris paste is ndibed into the ^traiuls of hemp, and
44 PLASTER OF PARIS AND HOW TO USE IT
more of the latter are added, from time to time, to im-
part the necessary thickness to the spHnt. First an an-
terior, and then a posterior, section is molded, and both
are held in contact with the limb by turns of a muslin
bandage. The latter is divided when the splints have
hardened, and these are now lined with non-absorbent
Fig- 39- Molding splint for fracture of humerus.
cotton and securely held in place by strips of adhesive
plaster and a muslin roller.
The Tricot Molded Splint
A length of tricot cylinder is filled with cotton or,
preferably, strands of hemp. It is then dipped in the
PLASTER OF PARIS AND HOW TO USE IT 4S
paste of plaster and thoroughly kneaded therein. When
completely impregnated, it is applied to the part and
shaped to it by turns of a muslin bandage, which holds
Fig. 40. Molded splint for fracture of humerus suspended to dry.
it in place while it is hardening. Like the other splints,
it is subsequently lined with non-absorbent cotton.
Molded Splint for Fracture of the Shoulder or
Arm
This splint should be made to extend from the root of
the neck to the elbow and to embrace the arm on all but
48 PLASTER OF P.^RIS JXD HOW TO USE IT
Hg. 43- A|vi»lymg sugar toiig sjilini, the furearm in prouadon.
k
PLASTER OF PARIS AXD HO IV TO USE IT 49
its mesial side. {ings. 41, 42,) With the aid of such a
molded splint, we can attain complete immobilization
when the splint is secured to the thorax with nmslin and
Kift. 44. HiililiiiK liitil Lilt' isilrtinilits uf ihe sugar (imi^ s]i]ini.
dextrin bandages. The elbow being left free, it may act
with the forearm as a connterextending factor.
CoLk's SprJNT. FuACTfRK OF THE FoRIiAKM
Here vvc may use an anterior, a posterior splint (Figs.
43 and 44), or, as in the ^'sngar-tong splint'* of Cole,
one piece hinged at the elbow. This latter splint is made
by passing a plaster of Paris bandage from the wrist
along the flexor aspect of the forearm, the latter being
held in a position of pronation (Fig. 43), and then, turn-
ing about the elbow, the bandage covers the extensor
surface of the forearm. The extremities of the batidage
PLASTER OF PARIS AND HOW TO USE IT 51
are held taut by the surgeon while it is setting. (Fig.
44.) The dressing is held in place by turns of a muslin
Braatz's Spiral Molded Splint
This bandage is suitable for fractures in the lower por-
tion of the forearm or CoUes' fracture. A strip of gauze
impregnated with plaster of Paris paste, or tricot cylinder
filled with plaster paste, is wound spirally about the
forearm, beginning at the elbow, just beneath the inter-
nal condyle, then, pass-
ing obliquely over the
flexor surface of the
forearm, it turns about
the radial side of the ,,. . t, . , • , , , ,
rig. 46. Braatz s spiral molded splint
forearm, passing over ^^^ Coiies' fracture.
the lower third of the radius on its dorsal surface, and
terminates at the head of the metacarpal bones. (Fig.
46.) The splint is finally lined with non-absorbent cot-
ton and covered with turns of muslin and starch band-
ages.
Molded Splint for I^^racturk of the Forearm
Several layers of crinolin, of appropriate length, are
dipped into a paste of plaster of Paris, and are then
applied to the dorsum of the forearm, from the elbow
to the heads of the metacarpal bones. The forearm is
allowed to rest on the thigh (Fig. 47), and if the fracture
be in the lower end of the radius or ulna the hand is
sharply flexed at the wrist, grasping the knee. Before
applying the splint, the arm is anointed with vaselin,
in order that the mold may be easily removed after it
has set. The splint is then lined with non-absorbent cot-
ton, dusted with dermatol : and secured to the forearm^
52 PLASTER OF PARIS AND HO IV TO USE IT
first by adhesive straps one inch wide, then by muslin
bandages, and lastly by a crinolin bandage. Instead of
the layers of crinolin, a roller bandage of plaster of
Paris, the width of the forearm, may be run up and
down, and molded to the shape of the limb.
Fig. 47. Posterior molded splint for fracture of one or both bones of the
forearm.
Gutter Splint
This splint is molded, in the same manner as the one
just described, about the foot, which is to be in the right-
angled position. It extends up the calf of the leg to the
flexure of the knee joint or above. (Fig. 48.) It is
suitable for fracture of the leg or injuries of the knee-
joint, when ambulatory treatment is deemed inadvisable.
PLASTER OF PARIS AND HOW TO USE IT 53
It is not eligible when there is any deformity, for the
splint embraces but half the inner and outer aspects of
Fig. 48. Plaster of Paris gutter splint for fracture of one or both bones
of the leg.
the leg. When dry, the splint is lined with non-absor-
bent cotton dusted with dermatol, and held in position
by muslin and crinolin bandages, applied successively.
54 PLASTER OF PARIS AXD HO IV TO USE IT
CHAPTER \T
PLASTER OF PARIS IN ORTHOPEDIC SUR-
GERY
Plaster of Parts Corset
It was this device as taught by Sayre that gave the
greatest impetus to the use of plaster of Paris dressings.
The manner of its apphcation laid down by him survives
to this day as the chosen method. A plaster of Paris
jacket may be applied with the patient either in the sus-
pended vertical position (Sayre), or in the swaying hor-
izontal, or recumbent position.
Vertical Suspension. — The patient is stripped of all
clothing. The body is cleaned with soap and water, rubbed
with alcohol, and freely dusted on all sides with talcum,
dermatol, bismuth, or a mixture of these. While in a
position as if crawling, /. e., with the body's weight sup-
ported on the hands and knees, a seamless shirt or tricot
hose is slipped on. If the latter is used, the upper end is
fitted by slitting the hose in the axillary lines to a depth
sufficient to bring the ends over the shoulder, where they
may be tied, or secured with a few stitches or a safety-
pin. All folds in the shirt are smoothed away by drawing
it down and securing it snugly in the perineum with a
safety-pin. The patient is lifted, with assistance if heavy,
into the suspension apparatus of Sayre; for with a dis-
eased spine, the patient should never assume, unsupported,
the erect posture. The patient is suspended in the ap-
paratus by the chin, with the arms extended and grasp-
ing the cross-bar to aid in the extension of the spine.
(Fig. 49.) The ropes that are fastened to the cross-bar
and play about the pulleys above, are drawn upon until
PLASTER OF PARIS AND HOW TO USE IT 55
the entire body sways, and the tips of the toes touch the
floor, or the stool placed beneath so that the patient's
trunk is on a level with the arms of the surg^eon seated
and applying the plaster bandages. An assistant grasps
the legs to prevent the swaying of the body, as well as
its rotation, and to £>;uard against the inadvertent dexion
Fig. 4^. Afjplicatioii uf pEiijjtcr jacket in Sayn^'s su&[>ciif
iisioti.
of the thighs. Another assistant controls the rope with
one hand, and with the other steadies the extended arms
of the patient* so as to prevent rotation of the cross-bar-
All the bony prominences, such as the spines of the
ilium, and the gibbns itself, and also any verv* decided
56 PLASTER OF PARIS AND HOW TO USE IT
hollow, especially about the waist line — if there be much
lateral curvature or lordosis — are covered with a thick-
ness of piano felt. This is to protect the prominences
from pressure, and to fill in the hollows, so that the sym-
metry of the jacket may prevent the plaster from crack-
ing. In each axilla felt or several thicknesses of gauze
will protect the skin from the friction of the edges of the
finished jacket. These pads are successively placed as
the turns of the bandage are about to grasp them. It
is no longer the practice to place a pad over the gastric
area to make allowance for the full or empty stomach.
If the patient rests comfortably in the suspended posi-
tion, the application of the plaster of Paris bandages may
follow. The bandages should be four inches wide for the
younger children, and for older children, of larger build,
six mches. The bandages are passed circularly around
the body. Below, the bandages should reach the great
trochanters, and above, they should pass under the axilla
and well over the top of the sternum. These limits of the
jacket must be w^ell borne in mind; for the commonly
committed failure to observe them is chiefly responsible
for ill-fitting corsets. If too short below, the jacket
presses into the abdomen, or the latter bulges out beneath
the edge of the plaster ; if not carried high enough, the
jacket fails to eflfect the necessary extension of the spine.
After the setting of the plaster is completed the patient
is to be lifted out of the swing. Being grasped by an
assistant from behind, his hands passing beneath the
axillae, the patient is borne on the chest of the assistant,
and is placed, temporarily, in the recumbent position.
Trimming the Jacket. — In order to allow flexion of
the thighs on the abdomen a crescent of plaster of suffi-
cient size is removed from each side, at the level of
Poupart's ligament. To allow adduction of the arms a
crescent-shaped piece is cut from the axillae. The band-
age must not be cut below the sternal notch, and a tongue
of plaster must be left about the symphysis pubis. The
PLASTER OF PARIS AND HOW TO USE IT S7
jacket must be cut on the sides until it conforms to the
upper limit of the great trochanter. The patient now
assumes the crawling attitude and the jacket is trimmed
above, straight across posteriorly from the upper limit of
one axillary fold to that of the other. Below, the excess
of plaster is cut across posteriorly at such a level that the
cast will not touch the chair seat when the patient is sit-
ting. If there be any sinuses leading into old abscesses,
the cast should be fenestrated, to admit of their being
dressed. Any small decubitus (pressure sore) which is
likely to form over the gibbosity may be dressed with
balsam of Peru under the jacket without fenestration.
The shirt or tricot hose extending beyond the cast is
drawn back over it and stitched together. This excess of
hose not only imparts a neat finish to the jacket, but
also prevents the rough cut edges of the plaster from
pressing into the soft parts. When an excess of shirt
or tricot is not available, the cast may be covered with
Fig. so. Plaster of Paris jacket provided with hooks for lacing.
58 PLASTER OF PARIS AXD HOW TO USE IT
several turns of a crinolin bandage, and the cut edges
covered with adhesive plaster. If the cast is to be a
permanent one, it is now completed. If, however, it is
to be a removable one it is to be cut down the front with
a mitre saw or Stilles' bone forceps while the trimming
is being done. The opposing front edges thus formed
are bound with adhesive plaster and are fastened to-
gether with the same material. For long-continued wear,
the edges should be bound with leather or canvas pro-
vided with a row of booklets. These are stitched on and
laces thrown about them. (Fig. 50.)
Jacket zinth Jury-Mast. — For the cervical form of
Pott's disease, it is customary to incorporate a jury-mast
in the dorsal part of the jacket. This latter device (as
illustrated in Fig. 51), is a band of steel, its lower end
having pieces of tin attached at right angles to facilitate
its fixation in the plaster cast. It is bent to conform to
the spine, and passes over the occiput to the vertex of the
Fig. SI. Plaster of Paris corset, with a jury-mast incorporated.
VIJSTER 01' FJRLS AXl) HOiV TO USE IT 59
skull. At this point there is attached a short bar which
plays on a pivot. From either end of the bar there
passes a piece of webbing or leather strap around the
chin to support tht; head. The band of steel should be so
bent as not to touch the spine or the head. The degree
of extension will be the greater the more the steel band
is carried away from the head.
Horhonta! Sits pens to tL-^\Whtn a suspension apparatus
is not at hand, the patient may be placed in the horizontal
position, face down, the body being stretched betw-een
two tables. (Fig. 52.) The shnnlders rest on a pillow
Fift. ^^^ Apitlicatiun of |»tas*ter of Paris corset in hurtznntal poi^itioii.
on one table, and the thi*2:hs on another. One assistant
is detailed to apply traction to the thighs, and another,
hooking his fingers in the axtllee, exercises traction up-
ward. The weight of the trunk effects a lordosis, there-
by overcoming atiy tendency to kyphosis. The same
precautions are to be observed as in Uie vertical method,
in covering any bony prominences. The plaster bandage
is passed in circular turns around the trunk.
6o PLASTER Of PARIS AS D HOW TO USE IT
Goldthwait's Method. — A jacket may also be applied
with the patient in a recumbent position, resting upon an
appliance consisting of two wire supports, on one of
which rests the sacrum, the other being placed beneath
the deformity (with pads intervening). With hyper-
extension, a sufficient leverage is exerted to correct the
deformity. The plaster bandage passes about the sup-
ports and includes the pads.
Horizontal Method in Hammoek. — In place of the
tables, again, a hammock made of extra stout muslin or
canvas is suspended between two chairs, or two wooden
horses, or over the ends of a bed. The patient is placed
therein, face downwards, arms and legs extended. The
plaster of Paris roller bandage, in its turns about the
body, includes the hammock. On the completion of the
bandaging, the excess of hammock is cut away. (Fig.
53-)
Application of plaster of Taris corset by horizontal method in
hammock.
The Bradford Frame is similar in application to the
hammock. It is a rectangular frame constructed of gas
pipe, over which is stretched a piece of canvas. The
patient rests on this, face down, arms extended, the
hands grasping the frame above, while the feet may be
drawn down bv an assistant ; or each foot, with the
PLASTER OF PARIS AND HO IV TO USE IT 6i
thighs in the abducted position, may be secured, with
traction, to the lower part of the frame. A sHt is then
cut in the canvas on each side of, and parallel with, the
body. Through these slits the roller bandage passes in
its turns about the body, to include the canvas bed. The
excess of canvas is cut away after the bandaging is com-
pleted.
Particulars About the Jacket. — The jacket should
weigh between one and two pounds, and should be of
uniform thickness throughout. If there is any decided
acuity of the symptoms it is far better not to split the
jacket, lest meddlesome guardians remove it too fre-
quently. A w^ell-fitting and comfortable jacket may re-
main in place for two months. At the expiration of this
time the condition of the skin demands consideration, and
the removal of the jacket is necessary for hygienic
reasons. Thereafter it may be provided with hooks and
laced, or brought together with strips of adhesive plaster,,
and so held in place.
A laced jacket is indicated in the less acute cases of
spondylitis, and where extensive wounds require surgical
dressing. Jackets are also indicated in cases of lateral
curvature to supplement gymnastics, and for cases in
which the distorted spine is painful. A plaster of Paris
corset is also indicated in fracture of the spine prior to
the performance of an operation, or when operation is
contraindicated ; and also after an operation has effec-
tually reduced the fracture. In some very exceptiona?
cases of rachitic curvature I have also applied a jacket
with benefit, for it prevented the movements of a very-
tender spine until anti-rachitic treatment became effective.
It may at times be necessary to extend the plaster
bandage so as to include the hip in a spica, as in sacro-
iliac disease, or in a complicating hip-joint affection ; and
if the spinal disease be in the upper cervical region the
turns of the plaster bandage should even pass about the
shoulders so as to carrv them well back.
62 PLASTER OF PARIS AND HO IV TO USE IT
The report of any pain, or the existence of any odor,
about the jacket is indicative of an open wound. This,
in the case of children, is commonly caused by the ex-
istence of a foreign body, playfully inserted or accident-
ally finding its way beneath the jacket.
A plaster jacket may be employed as a mold, from
which, by filling the interior with a mixture of plaster of
Paris, a cast of the deformity can be made. Over this
cast corsets of other material — felt, wood, veneering,
aluminum, and celluloid — may, in turn, be molded.
If a jury-mast be not obtainable, a crown of plaster of
Paris may be passed about the head and this then joined
by two steel bands passing to the plaster jacket and in-
corporated in its turns. (Fig. 54.)
Fig. 54. Plaster of l*aris corset and coronet united by bands of steel.
Suitable for immobilization of the spine or for torticollis.
PLASTER OF PARIS AND HOW TO USE IT 63
LoRENz Bed
In young infants who are to be carried about, a plaster
jacket is impractical because of its weight, and because
it impedes the thoracic movements. As such infants do
not assume a sitting or an erect posture, they are best
treated in recumbency. For this purpose the Lorenz
bed is admirable. (Fig. 55.) It is a splint molded to
Fig. 55. Asterisks denote the Lorenz plaster of Paris bed for tuberculous
spondylitis.
the contour of the spine, extending laterally to the pos-
terior axillary line. When the disease is in the upper
spine, it may be molded about the neck and head. It is
to be padded with non-absorbent cotton, and secured to
the trunk by turns of muslin and crinolin bandages.
Plaster Collar and Jacket
When the disease of the spine is high up in the dor-
sal region, or in the lower cervical, the bandages may be
extended around the neck (Fig. 56) in figure-of-eight
turns ; or by like turns the head may be fixed ; or a sep-
arate collar (Fig. 57) may be made, impinging upon the
mastoid processes embracing the lower jaw, extending
well onto the shoulders, and resting upon the clavicles.
These plaster investments for the neck are indicated in
the correction of torticollis, or after resection of the
64 PLASTER OF PARIS AND HOW TO USE IT
sterno-mastoid for spasmodic torticollis, and for fracture
of the cervical spine.
Fig. 56. Plaster of Paris jacket with figure-of-eight turns about the neck
for cervical spondylitis or torticollis.
Torticollis
During the period of time, when non-operative meas-
ures are resorted to, in the hope of correcting wry-neck,
the deviation of the head dependent on congenital spastic
contraction of the sterno-mastoid muscle, may be over-
come by suspension in the Sayre's apparatus. Where
this can be accomplished, the position may be maintained
by investing the body with a plaster of Paris jacket of
light construction and extending it so as to pass about
the neck in figure-of-eight turns (Fig. 56) or, if the
PLASTER OF PARIS AXD HOir TO USE Tl 65
muscle be more unyieldini^, the plaster of Paris should
also inclutk' the licad, eJicircliiii:,^ the ncclpiit anil fmntal
bone.
In the acquired form of torticollis, which can bo ea.^ily
righted by niaiuial force, the head can he retained in a
corrected position by placing about it a coronet made of
^>S' 57- Plaster of Paris oiiUat
plaster of Paris, into which a metal rin^ is hicorporated.
by means of a mnshn bandage passing through the ring
and about the thigh, traction is made in a direction oppo-
site to the existing torticollis. This traction is carried
to the extent of producing a torticollis on the (jpposite
side, thereby overcoming the spamn of the affected side.
For the torticoIHs of ccri'ical J^/^ofniyHtis a wcU-fittinf:
66 PLASTER OF PARIS AND HOW TO USE IT
plaster of Paris corset with a jury-mast from which the
head is suspended, is the best form of treatment.
Hip Joint Disease
A plaster of Paris spica passing about the lower thorax
and extending within a few inches of, and at times includ-
ing, the knee joint, is an effective way of immobilizing
the diseased hip joint. The spica is not to be applied,
however, until flexion and abduction deformities have
been overcome by extension with weights. The presence
of a large, cold abscess, or sinuses leading into the bone
or joint, contraindicate the use of a plaster of Paris spica.
Fig. 58. Plaster of Paris coronet with ring incorporated to aid in cor-
rection of torticollis.
Even if it be desirable to apply some form of brace, or
traction splint, the plaster spica may be retained when the
tendency to flexion and abduction are marked. When
PLASTER OF PARIS AND HOW TO USE IT 67
sole reliance for fixation is placed upon the spica, the
immobilized, diseased side should be kept from the ground
by the use of crutches. On the whole, it must be said,
that the plaster spica, however well applied, is a bulky
and unclean means of treating hip joint disease, as com-
pared with some form of metal splint. As a word of
warning, it should never occur to anyone to apply the
plaster spica in order to correct a deformity.
Application of the Hip Spica. — The method of apply-
ing a plaster hip spica, described in fractures of the thigh,
are equally applicable in hip joint disease. In addition
to these, the following will be found useful. The head
Tf
Fig. 59. Application of hip spica in the horizontal position.
and chest of the patient rest upon a table. Both limbs
extended, and with the feet resting on another table
or horse, are grasped by an assistant who exerts traction.
Another assistant by hooking his hands into the axilla
exerts counter-extension. With the body thus suspended,,
in the horizontal position, the plaster hip spica can be
easily applied. (Fig. 59.)
Knee Joint Disease
An effusion of serum or blood in the knee joint, can
very often be rapidly dispelled by the absolute immobili-
zation afforded by a plaster cast, investing the thigh,,
including the knee joint, and extending down the leg
below the calf. A cast of the same extent is necessary in
68 PLASTER OF PARIS ASD HOW TO USE IT
tuberculous disease of the knee joint, but not until the
flexion deformity has been overcome by gradual exten-
sion, with weights and pulleys. The knee joint immo-
bilized in the cast (of light construction) must not sup-
port the superimposed weight of the body, therefore
crutches are to be worn or the knee, encased in plaster
of Paris, is suspended in the Thomas splint for knee
joint disease.
Ankle Joint Disease
In all affections of the ankle, there is a great tendency
for the foot to assume a position of equinus combined at
times with eversion (valgus). To forestall this, the foot
must very early be placed in a plaster of Paris cast, in a
position at right angles to the leg. Where there is much
spasm of the tendo Achilles, this may be overcome by the
administration of an anesthetic, and if there be still some
difiiculty, a subcutaneous tenotomy must be resorted to
before applying the plaster cast.
Flat Foot
The rigid flat foot, with spasm of the tendo Achilles
and lack of mobility of the smaller articulations, and
abduction and eversion in the medio-tarsal articulation,
calls for a correction which can be maintained only by
a plaster of Paris dressing. To effect a correction, it is
necessary to administer an anesthetic and manually force
the foot into an exaggerated adducted (varus) position.
It is thus maintained by a plaster of Paris dressing, which
extends half way up the leg. This plaster cast remains
on for four weeks. For the first three weeks the patient
occupies the recumbent posture; thereafter he may walk
about with crutches. At the expiration of the fourth
week the dressing is removed and a plaster mold made,
either from the dressing or directly from the foot. A
sheet of steel is then hammered to conform to the plaster
PLASTER OF PARIS AND HOW TO USE IT 69
mold, on its plantar surface, as far forward as the head
of the first metatarsal bone, and to pass obliquely out-
wards back of the heads of the metatarsal bones, to the
cuboid, the posterior limit of this splint corresponding to
the middle of the os calcis. On the inner aspect of the
cast the splint is hammered out in a semi-ellipse extend-
ing to the internal malleolus. On the outer aspect a
Fig. 60. Lorenz spica for unilateral congenital dislocation of the hip.
tongue of metal is hammered out as a guide to prevent
the splint from slipping. This accurately fitted splint,
thus hammered out over the plaster mold, is placed in
the shoe, and, acting as a lever, it forces the foot into the
correct position.
Congenital Hip Dislocation
One of the essentials in the successful treatment of a
congenital dislocation of the hip is the application of a
70 PLASTER OF PARIS AND HOW TO USE IT
well-fitting hip spica in which the patient walks about.
An X-ray picture is first taken as a guide to the location
of the head of the femur. Then follows a reduction of
the head into the acetabulum, in which it is maintained
by abducting the limb. In this abducted position the uni-
lateral or bilateral spica is applied, according as the dis-
location has been on one or on both sides. (Figs 60 and
61.) In addition to the abduction, the limb is slightly
flexed and rotated in. The spica should preferably pass
well up on the thorax, though this is by no means abso-
lutely necessary. It should not extend below the knee.
Fig. 61. Double spica for bilateral congenital dislocation of the hip.
in order not to interfere with comfort in walking. The
plaster cast remains on at least six weeks. At the ex-
piration of this time it is removed. If a radiograph
then made shows the head of the femur in the acetabulum,
the degree of abduction is lessened gradually. All the
time that the cast is on, the patient walks about, thus aid-
ing by this pressure, in forcing the head into the aceta-
bulum and in shaping the latter. After the removal of
the last cast, a hip splint is to be worn for some months.
Club Foot
The deformity known as club foot, if treated immedi-
ately after birth, and persistently, can be wholly corrected
PLASTER OF PARIS AND HOW TO USE IT 71
by the use of plaster of Paris dressings, within a year or
two. It is necessary, by a process of manipulations, as in
modeling, to bring the foot from its equinus position into
that of a right angle with the leg and to overcome the
adduction (varus) and inward rotation. When these
have been corrected a plaster of Paris cast is made to
invest the foot, extending up the leg to the condyles of
Fig. 62. Wolff's method of removing wedge from cast to better the
correction of the club foot.
the tibia. Great care must be taken in padding the bony
prominences with non-absorbent cotton to prevent pres-
sure sores. The best guarantee against decubitus, is a
thorough reduction of all the abnormal positions that
occasion the prominences. If the deformity cannot be
wholly corrected at the first sitting it is remedied after
the removal of the cast. With each renewal of the cast
*J2 PLASTER OF PARIS AXD HO IV TO USE IT
another attempt is made to better the position of the foot.
This correction of the ver}- plastic tissues of the new-
born and of the infant calls for no anesthetic. In adults,
however, narcosis is necessary.
Wolff's Method. — The correction is effected under
anesthesia, and a plaster cast is applied. While this is
setting, further correction of the deformity is made by
abducting the foot. Over the outer malleolus and over
the tuberosity of the head of the first metatarsal bone
fenestne are cut to relieve the pressure. At the end of
the first week a wedge is cut from the outer aspect of
the cast (Fig. 62), and a linear division made about the
ankle joint to the inner aspect of the foot. The removal
of the wedge permits of crowding the foot outwards to
effect a better correction. For this, and for succeeding
corrections, rendered possible by enlarging the wedge
removed, no anesthetic is called for. After each wedge
cutting from the plaster, and correction, another layer of
plaster of Paris is applied to hold the foot in its new
position. When the complete correction of the foot has
resulted, the cast is covered with strips of basswood
veneering. These are secured in place by crinolin band-
ages, and coated with glue. A "water-glass" (silicate of
soda) bandage is placed over all. The patient is allowed
to walk about in this dressing for a month or a year, de-
pending on the degree of severity of the condition.
PLASTER OF PARIS AND HOW TO USE IT 73
CHAPTER VII
Plaster op' Paris in Dental Surgery
All varieties of commercial plaster of Paris will make
good models, but none other than recalcined plaster, sold
in the shops under the name of French Dental Plaster, is
suitable for making impressions.
Mixing the Plaster
Place four ounces of water in a bowl, preferably of
rubber ; but a glazed porcelain bowl will answer the pur-
pose. It is advisable to have the plaster set as quickly as
possible, therefore add
a pinch of salt, alum
or chlorate of potash.
If none of these is at
hand, warm water will
hasten the setting. The ^^
addition of a few drops
of essence of pepper-
mint to the water will
dispel the unpleasant
taste of the plaster in
the mouth. Take up
the plaster on an or-
dinary spatula and sprinkle it on top of the water. Allow
the plaster to be completely taken up before repeating
this procedure; and do this a number of times until the
water has absorbed all the plaster it can possibly take up.
By following this slow method air bubbles will be pre-
vented from forming. Then stir the mass with a spatula,
in one direction only, until it has the consistency of a
thick cream. Place it in the impression tray (Figs. 63
63. Dental impression tray
endentulous upper jaw.
for
74 PLASTER OF PARIS A^D HOW TO USE IT
and 64), which should be previously selected to lit the
mouth as nearly as possible, so that the minimum amount
of plaster should be inserted in the mouth. If the im-
pression is to be taken of the upper jaw, the tray should
be first pressed up against
the posterior aspect of the
mouth, and subsequently the
anterior part of the tray
should be pressed into posi-
tion in front. This will cause
all surplus of plaster to be
forced out of the mouth,
— — ^ thereby preventing: efaefefine:
l'»g 134, Iknital impression iray for ' ^ 00 00 o
upper jaw, some teeth being ^j- naUSCa tO a 9:reat CXteut.
present. °
Preparation of the
Patient
Gagging, nausea and vomiting may be more certianly
guarded against by spraying the palate and mouth with
Fig. 65. Model of hypertrophied jaw.
PLASTER OF PARIS AND HOW TO USE IT 75
a half of one per cent, solution of eucain or cocain, sup-
plemented by the internal administration . of a dram of
aromatic spirits of ammonia. In sensitive patients, the
best guarantee against nausea, etc., is the injunction to
have the stomach empty.
Plaster intended for impressions of the lower jaw
should be of such thick consistency that the tray may be
inverted without the plaster falling therefrom. In taking
an impression where it is impossible to withdraw it in
one piece, it is desirable to mix with the plaster from one-
third to one-half of ordinary precipitated chalk. This
will cause the impression of fracture more readily and
thus permit of replacing the parts afterwards, to make
the model. In the case of cleft palates where a large
fissure exists, it is advisable, prior to taking the impres-
sion, to either obliterate the fissure with softened bees-
wax, or absorbent cotton, or to bridge it over with ad-
hesive plaster, the buccal surface of which must be oiled.
The wax and cotton are apt to adhere to the impression,
but if these precautions ?rc not ohFcrvcd, the plaster of
l-'ig. 66. Model of a syphilitic perforation.
Paris will run up into the fissure, and in withdrawing it
a laceration of the soft parts may ensue. When the fis-
sure extends to the soft palate, an impression of the
76 PLASTER OF PARIS AXD HO IV TO USE IT
hard parts is all that is required, as the posterior portion
is subsequently modeled in the mouth.
Difficult Impressions
Wherever there is a chance that the impression will be
difficult to remove, as in the case of tumors of the jaw,
it is advisable to oil the impression tray before placing
the plaster in it. This will allow the tray to be removed,
leaving the hardened impression in the mouth, thereby
permitting the operator to cut it away in sections, which
can be replaced in the proper position and a model made
therefrom.
Impressions for Fracture of the Jaw
Impressions of a fractured jaw should not be taken in
plaster of Paris, for modeling composition is far superior
for this purpose.
Fig. 67. Model of a cleft palate.
PLASTER OF PARIS AND HOW TO USE IT 77
Where an operation is contemplated, it is advisable to
take an impression of the mouth prior to the renioval of
the pathological condition (tumor), as this will serve as a
guide in making the prosthetic appliance thereafter.
Making the Plaster Models
In order to obtain the best models it is absolutely necesr
sary that the impressions be perfect, that all of these are
in their proper position before the model is poured.
Plaster for models should contain the same ingredients
as for impressions, but it should be somewhat thinner in
consistency since it has to be poured.
The Separating Media Between Impressions and
Models
To facilitate the separation of the impression from the
model, a separating medium is necessary, so that one does
not adhere to the other. Various solutions can be utilized
for this purpose. A very thin alcoholic solution of shel-
lac, or water-glass, or ordinary soapsuds, colored with
Fig. 68. Kingsley obturator for cleft palate attached to plate.
red ink to thereby indicate the line of demarcation be-
tween the impression and the model, will answer the pur-
pose. Oil and vaselin should not l)e used, for they soften
the surface of the model.
78 PLASTER OP PARIS AXD HOW TO USE IT
With a camel's hair brush, coat the impression with
any of these separating materials and allow to dry. Then
soak the entire impression in water of the body tempera-
ture. The object of this step is to facilitate the flowing
of the model plaster into at the small crevices, which
will not happen if the impression is dry. Place a small
quantity of plaster intended for the model, on the high-
est portion of the impression, then tap the impression
gently on the table or with the handle of the spatula, so
Fig. 69. Kingsley cleft palate obturator covering the cleft.
that the plaster will flow down into all the crevices an<l
depressions. Repeat this as often as is necessary to build
the models to the desired form. This will prevent bub-
bles, expel the air from the crevices of the impression and
give a most satisfactory model.
PLASTER OF PARIS AND HOW TO USE IT 79
After the plaster has hardened, place the whole in a
pan of water, and allow it to boil five minutes. The ex-
pansion caused by the heat will facilitate the separation
of model from impression. If it is a simple impression
w^ithout undercuts to cause adhesion, merely tapping the
model with the handle of the spatula will effect the sepa-
ration. If the separation is hindered, however, by any
irregularities in the impression, the latter has to be cut
away in small pieces until the line of demarcation of the
separating material is reached. This may be supple-
mented by occasional tappings with the handle of the
knife to loosen the parts.
In making a plaster model from a wax, or modeling
compound, impression, as in fracture of the jaw, wet the
impression, pour the plaster in the same manner, allow
it to set, place in a pan of cold water and do not boil,
but merely heat it until the impression material is thor-
oughly softened, when it can be easily withdrawn from
the model.
Fig. 70. Model of a fracture of the jaw.
Models should be neatly trimmed and dusted with
talcum powder, to give them a smooth surface.
8o PLASTER OF PARIS AND HOW TO USE IT
Interdental Splints
The first requisite is to take an impression in wax
or modeling composition and then to make a plas-
ter model of both jaws. (Fig. 70.) Then the
model of the fractured jaw is so cut and replaced
on an appliance for that purpose, known as an ar-
ticulator (Fig. 71), as to bring the teeth of the up-
per and lower jaw in normal occlusion. On these
models the model of the interdental splint is made in
wax, and from this it is made in vulcanite (Fig. 72) or
cast in pure tin. It is advisable to paint the cusps of the
teeth on the models with several coats of shellac or to
burnish over the cusps with No. 60 tin foil. The object
of the latter procedure is that the indentations in the
splint shall be a trifle larger than the teeth in the mouth,
thereby permitting the reduction of the fracture more
readily when the splint is inserted.
^Todel of a primitive articulation in plaster.
If it is a difficult or painful procedure to insert the
splint in the mouth, and reduction is possible forthwith,
an anesthetic is administered to relax the muscles.
When reduction is not possible at the first sitting, the
splint may be inserted and a tight Barton's bandage
placed about the head. In a few days normal occlusion
will thus be attained.
PLASTER OF PARIS AND HOW TO USE IT 8i
Plaster Models of the Body
When the impression is to be made of a complicated
part of the body, as a foot or hand, it is desirable to make
it in two sections, and, furthermore if the part be covered
with hair it had better be anointed with vaselin to pre-
vent the plaster of Paris from adhering. The plaster
for the first half of the impression may be of firm con-
sistence and spread upon a layer of gauze. This half ap-
plied, the remaining surface of the part and the corre-
sponding surface of the half of the impression that has
been applied, are coated with a separating material (col-
ored soapsuds, shellac or water-glass), and then the plas-
ter of thinner consistence is poured over until it covers
the part completely. When the plaster is set the impres-
sions are separated. A model is made by tying the halves
Fi^. 72. Interdental splint with fenestra in the center for feeding.
S2 PLASTER OF PARIS AXD HOW TO USE IT
of the impressions together after coating their inner sur-
faces with separating material (appHed with a camel's
hair brush), and then a thin cream of plaster is poured
into the interior of the impression, into the furthest end of
which a perforation is made to permit the escape of air,
thus to avoid the formation of bubbles.
Repair and Preservation of Models
Any broken model may be repaired with cement,
^lodels may be prepared for preservation by boiling in a
solution of alum, and then coating when dry, with shellac.
Plaster Impressions and Moulages of Skin Diseases
To make wax models (moulages) of skin lesions, an
impression is first made in plaster of Paris. This im-
pression, when hard, is moistened in hot water, and then
a mixture of melted beeswax, and spermaceti, equal parts,
is poured on the impression. The wax model is easy
to separate from the moistened impression. The coloring
is subsequently imparted to the wax model with
pigments.
INDEX
A
page:
Adjuvants, Chemical 7
Alum 7, II
Salt 7, II, 19.
Ambulatory Cast 32
Application of Plaster 8
B
Bandages, Plaster:
Commercial 3.
Hand-made 2
Wire 3,
Bavarian Splint 41
Braatz's Splint 51
C
Cast:
Ambulatory 32-
Removal of 11
Replacement of 14.
Splitting of 17, 18
Cole's Splint (Sugar-tong) 49
Colles' Fracture 21
Collar Plaster 63.
Containers, Tin 3
Club- Foot :
Woolf 's Method -72, 73.
83
84 INDEX
PAGE
Corset 54
Bradford Frame 60
Goldthwait Method 60
Horizontal Method 60
Trimming of 56
Vertical Method 54
Cuff 10
D
Dental Surgery 73
Dental Plaster 73
Mixing Plaster 73
Tray Impression 73, 74
Dextrine Bandage i
Disease :
Hip Joint 66
Knee Joint 67
Ankle Joint 68
F
Fiat-Foot 68
Fractures :
Ankle Joint 29
Carpal Bones 23
Colles' 21
Elbow Joint 21
Femur (Shaft) 28
Foot 31
Forearm 19
Humerus 20
Hip-Joint 25
Jaw 80
Metacarpal 23
Olecranon Process 34
INDEX 85
PAGE
Patella 33
Thumb 22
Tibia 29
Fraying of Bandage 6
G
Gigli-Saw 11
Gutter Splint 52
H
Hemp-Splint 43
Hip-rest 26
Hip:
Fracture 25
Joint Disease 66
Spica 67, 25, 27
J
Jacket 54
Jury Afast 58
L
Lorenz Bed 63
Lorenz Spica 69
M
Massage 8
Materials
Cotton
Crinoline
Deimel Mesh
Dextrine
Flax
Flannel
Gauze
Hemp
86 INDEX
PAGE
Jute
Muslin
Sail Cloth ^
Straw
Tricot
Mitre Saw 13
Molded Splints 38
Model, Plaster:
Cleft Palate 67
Fracture of the Jaw 70
Hypertrophied Jaw 65
Making of yy
Preservation 82
Repair of 82
Separating Media yy
Syphilitic Perforation 75
Moulages 82
P
Paralysis, Ischemic 18
Plaster Bandage:
Continuity 9
Fractures 16
General Considerations 16
Precautions 8
Removal of 24
Sections 9
Posture 18
Protection Skin 7
Soiling 4
R
Refuse, Disposal of 15
Removal Bandage 15
Removal Plaster 11
Sugar 15
Salt 15
INDEX 87
S
PAGE
Saw :
Gigli 11
Mitre 13
Sections — Plaster 9
Shears, Stilles 13
Spica :
Hip 67, 25
Lorenz 69
Thumb 23
SpHnts :
Ambulatory 32
Bavarian 41
Braatz's . 51
Compound 34
Fenestrated 31
Gutter 52
Heated ]^6
Hemp 43
Interdental 80, 82
Molded 38
Segmented 35
Sugar-tong 49
Suspended 36
Tricot 44
T
Torticollis 64
Tricot-hose 29
Splint 44
Trimming Corset 56
\^
X'eneering 34
88 INDEX
W
PAGE
Wire Bandage 3
Wolff:
Clnb-foot 70, 71
X
X-Ray :
Fractures 16, 24
Congenital Hip 69
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