When would you use a 4-point gait with crutches?

1-13. CRUTCH WALKING GAITS

a. The 4-point gait (see figure 1-8) is used when the patient can bear some weight on both lower extremities. Place the patient in the tripod position and instruct him to do the following.

(1) Move the right crutch forward.

(2) Move the left foot forward.

(3) Move the left crutch forward.

(4) Move the right foot forward.

(5) Repeat this sequence of crutch-foot-crutch-foot for desired ambulation.

Figure 1-8. 4-point crutch walking gait.

b. The 3-point gait (see figure 1-9) is used when the patient should not bear any weight on the affected leg. Place the patient in the tripod position and instruct him to do the following.

(1) Move the affected (non-weight bearing) leg and both crutches forward together.

(2) Move the unaffected (weight bearing) leg forward.

(3) Repeat this sequence for desired ambulation.

Figure 1-9. 3-point crutch walking gait.

c. The 2-point gait (see figure 1-10) is used when the patient can bear some weight on both lower extremities. Place the patient in the tripod position and instruct him to do the following.

(1) Move the right leg and left crutch forward together.

(2) Move the left leg and the right crutch forward together.

(3) Repeat this sequence for desired ambulation.

Figure 1-10. 2-point crutch walking gait.

d. Swing-through gait (see figure 1-11) is used for patients with lower extremities that are paralyzed and/or in braces. Place the patient in the tripod position and instruct him to do the following:

(1) Move both crutches forward together about 6 inches.

(2) Move both legs forward together about 6 inches.

(3) Repeat the sequence in rhythm for desired ambulation.

Figure 1-11. Swing-through gait.

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The Brookside Associates Medical Education Division develops and distributes medical information that may be useful to medical professionals and those in training to become medical professionals. This website is privately-held and not connected to any governmental agency. The views expressed here are those of the authors, and unless otherwise noted, do not necessarily reflect the views of the Brookside Associates, Ltd., or any governmental or private organizations. All writings, discussions, and publications on this website are unclassified.

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1-17. CARE OF THE PATIENT WITH A NEWLY APPLIED CAST

a. Expose a newly applied cast to air circulation. It should never be covered, because the cover will restrict the escape of moisture and heat. This is essential, as a drying cast generates heat within the plaster as the moisture evaporates and the cast hardens.

b. Handle a wet cast carefully. A newly applied cast is set and firm when the patient leaves the cast room, but it is still damp and easily damaged. It takes 24-48 hours for a cast to become dry and hard. Handle the cast by lifting and supporting it on a pillow or with the palms of the hands. Never use fingers as they will leave indentations, which cause pressure areas within the cast.

c. Provide plastic-covered pillows to support the cast along its entire length. Never permit the wet cast to rest directly on a flat or firm surface as this will flatten the contours of the cast and cause pressure within the cast.

d. Review the patient's clinical record for the type of cast and the reason the cast has been applied. Interview the patient to determine his knowledge of the cast purpose and whether he has had a cast before. Instruct the patient on care of the cast that is wet and after it is dry.

e. After a cast has cooled and begins to harden, elevate the casted extremity to reduce swelling which often occurs after application of a cast. When a newly applied cast is elevated, it should be supported along its entire length, on an inclined plane, with the distal joints higher than the proximal joints. For example, hand higher than elbow, elbow higher than shoulder.

f. Observe all edges of the cast for any areas that cut or put pressure on the skin.

g. Observe the extremity encased in plaster for circulatory impairment by comparing fingers or toes of the casted extremity with the uninvolved extremity. The primary concern following new cast application is to prevent complications. Circulation should be checked hourly during the first 24 to 48 hours, then every 4 hours.

(1) Check the skin temperature of the injured extremity. It should not be colder than the unaffected limb.

(2) Check and compare the pulses. They should be equal.

(3) Check for complaints of numbness, tingling, burning, swelling, pain, pressure, or inability to move the fingers or toes.

(4) Report presence of the above signs and symptoms IMMEDIATELY to avoid possible tissue necrosis; these findings indicate possible ischemia.

h. Perform the blanching (capillary refill) test. The nail beds of the fingers or toes are compressed lightly and released to check how quickly the color returns.

(1) With pressure applied, the nail bed should turn pale (blanch). When pressure is released, the color should return within the time it takes to say "capillary refill," indicating return of capillary action.

(2) Failure to blanch, or a blue tinge, indicates impaired venous circulation and congestion of tissues.

(3) Failure of color to return, or cold, pale fingers or toes suggests impaired arterial circulation.

(4) In either case, report findings IMMEDIATELY. Do not wait. Permanent damage can result from impaired circulation caused by cast pressure.

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Casts may be cut for different reasons--to allow for wound dressings, to examine a painful area, or to relieve pressure. Nursing personnel may be required to assist with cast cutting at the bedside as an emergency measure.

a. Bivalving the Cast. Bivalving is the recommended method for emergency cutting to relieve pressure. In bivalving, the cast must be cut along its entire length on two sides (medial and lateral) and the base lining or padding cut completely down to the skin. If the cast or the lining is split only part way, the congestion will be increased and additional tissue damage will occur. To cut the cast, use a knife, a hand cutter, or an electric cast cutter. Use bandage scissors to cut the base material. To use a knife for emergency cast cutting, follow these steps.

(1) Make a shallow groove to indicate the cutting lines on both sides of the cast.

(2) Apply water or peroxide along the cutting lines to soften the plaster. Use a syringe to apply.

(3) With the knife, cut through the layers of plaster along the cutting line. Do not attempt to slice through all layers at once and do not use the knife to cut through the base material.

(4) With the bandage scissors, cut through the base material down to the skin. Cut every thread of the lining material completely through since the lining is sometimes the source of the trouble.

(5) Use tape or an elastic bandage to loosely hold the bivalve cast together in order to maintain support of the casted part until further instructions are obtained.

b. Windowing the Cast. This procedure is done on specific order of the physician. It is a potentially dangerous procedure because the underlying tissue may bulge through the window opening, causing "window edema." If a window is cut, the piece of plaster removed should be saved.

(1) The physician indicates the area to be windowed.

(2) The physician or orthopedic technician cuts the window, usually a square or rectangular area, out of the cast. Once the plaster has been cut out, the lining material is carefully cut away from the skin.

(3) After the physician examines and treats the underlying area, a dressing may be applied over the exposed skin area and the cutout piece of plaster bound in place again. Replacing the cutout plaster section will prevent window edema.

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1-20. GENERAL NURSING MANAGEMENT OF THE PATIENT WITH A CAST

a. Although a patient with an arm or leg cast is much more self-reliant than a patient in a body or spice cast, it is a nursing responsibility to monitor all patients and assist as needed. Nursing management includes the following actions to assess the effectiveness of the cast.

(1) Check the edges of the cast and all skin areas where the cast edges may cause pressure. If there are signs of edema or circulatory impairment, notify the charge nurse or physician immediately.

(2) Slip your fingers under the cast edges to detect any plaster crumbs or other foreign material. Move the skin back and forth gently to stimulate circulation.

(3) Lean down and smell the cast to detect odors indicating tissue damage. A musty or moldy odor at the surface of the cast may be the first indication that necrosis from pressure has developed underneath.

(4) Check the integrity of the cast by looking for cracks, breaks, and soft spots.

b. The casted body part must be examined and assessed frequently in order to prevent complications. Assess the casted part by checking the following.

(1) Assess circulation by performing the blanching test and comparing the skin temperature and blanching reaction of the affected limb to that of the unaffected limb.

(2) Assess the presence of sensation in the affected limb by touching exposed areas of skin and instructing the patient to describe what he felt.

(3) Assess the motor ability of the affected limb by having the patient wiggle his fingers or toes.

c. Patient education will do much to prevent complications. Instruct the patient to do the following.

(1) Avoid resting cast on hard surfaces or sharp edges that may dent the cast and cause pressure areas.

(2) Never use a coat hanger or other foreign object to "scratch" inside the cast. This may cause skin damage and infection.

(3) Report any danger signs to the nursing staff immediately. Danger signs include pale, cold fingers or toes, tingling, numbness, increased pain, pressure spots, odor, or feeling that the cast has become too tight.

(4) Report any damage to the cast such as cracks, breaks, or soft spots.

(5) Never attempt to remove or alter the cast.

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1-21. NURSING MANAGEMENT OF PATIENTS WITH EXTREMITY CASTS

a. After a leg cast is applied, prevent or alleviate swelling by elevating the extremity above the level of the heart. After the patient begins to ambulate, he should be encouraged to elevate the casted extremity when he is seated or resting in bed.

b. To control swelling with an arm cast, elevate the extremity on pillows or suspend in stockinet from an IV pole when the patient is lying or sitting. When the patient is ambulatory, a sling may be used for support. The type of sling required will depend upon the type of cast applied. A standard short arm cast or long arm cast can normally be adequately supported with the triangular bandage sling. See figure 1-13. [Note: Cast is not shown.] A sling does not support the arm above heart level so, in order to promote drainage and reduce swelling, the patient should be encouraged to remove the sling and raise the arm above his head periodically.

Figure 1-13. Triangular bandage sling.

c. If permitted by the physician, the patient should be encouraged to exercise his muscles. Isometric muscle contractions (contracting the muscle without moving the part) may be done to prevent atrophy and maintain muscle strength.

(1) If the patient is in a leg cast, have him lie down, place your hand under his knee and instruct him to "push down" toward your hand.

(2) If the patient has an arm cast, instruct him to make and release a tight fist.

(3) Encourage the patient to wiggle his fingers and toes frequently.

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1-22. NURSING MANAGEMENT OF PATIENTS WITH BODY OR SPICA CASTS

a. When a large cast, such as a body cast or spice cast, is applied, the curves of the cast must be supported in order to prevent sagging and pressure. Support should be given to the entire cast, especially at weak areas such as the shoulder, hip, and knee. Small plastic-covered pillows should be placed under the cast in such a manner that there are no gaps between pillows.

b. A patient in a large cast will not be able to bathe without assistance. However, the patient must be

encouraged to do as much for himself as is possible. Nursing personnel assist with those hygiene needs that the patient cannot manage alone. Each time the patient is turned to the prone position, wash the exposed back and buttocks and dry thoroughly. Apply lotion or powder and gently massage the skin to stimulate circulation.

c. When assisting with a urinal or bedpan, elevate the back and shoulders slightly higher than the buttocks to prevent dampening or soiling of the cast. Pillows may be used for support or, if the physician permits, the bed may be gatched up.

(1) Assist male patients with placement and removal of the urinal, if necessary.

(2) An emesis basin, slipped in place lengthwise, may be used by female patient for voiding. The basin is easier to place and remove than a bed pan.

(3) When assisting a patient with a bedpan, be certain that the buttocks are resting on the rim of the bedpan. The patient's head, shoulders, and back should be higher than the buttocks if at all possible.

(4) When a trapeze can be used, instruct the patient to lift straight up in order to avoid friction on the skin when placing and removing the bedpan.

(5) After using the urinal or bedpan, assist the patient to clean himself thoroughly. Check cast edges for soiling or dampness.

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1-23. TURNING A PATIENT IN A SPICA CAST

Patients in body or spice casts must be turned from supine to prone to permit the cast to dry, to prevent pressure areas by redistribution of body weight, and to prevent respiratory and urinary complications. The patient is turned initially as ordered by the physician and must usually be turned a minimum of every two hours (unless otherwise indicated by the physician) for as long as he remains in the cast. Until the cast is thoroughly dry, at least three people should turn the patient so that there is no strain on the patient or on the damp cast. As the patient becomes accustomed to the cast and learns to help himself, less assistance may be required in turning the patient.

a. In any turning procedure, the patient must be turned "as a unit" with the affected side ("bad side") uppermost. The patient should be turned, or log-rolled, toward the unaffected side of his body ("good side").

b. Utilizing the pillows on which the patient is resting, and/or a draw sheet, move the patient to the side of the bed with a steady, even, pulling motion. Remember that

the patient must be moved as a unit. When the patient is in the proper position, his "bad side" will be at the edge of the bed and his "good side" will be near the center of the bed.

c. One person should remain at the patient's affected side, while the others move to the opposite side of the bed to straighten the bed linen and position another set of pillows along side the patient. The pillows should be arranged so that they will support the cast and the patient's head and shoulders when you turn the patient.

d. The patient should be instructed to raise the arm on his unaffected side above his head.

e. The person on the patient's affected side should place his hands, with palms up, under the patient's torso.

f. The assistants on the patient's unaffected side should reach across the bed and place their hands, with palms down, on the patient's affected side. The person nearest the patient's head should place his hands on the patient's shoulder while the person nearest the patient's feet should place his hands on the patient's hip and leg.

g. Moving simultaneously, the person on the patient's affected side should gently draw the patient toward himself while the assistants on the opposite side ease the patient over toward themselves. Care should be taken to support the leg and arm on the affected side of the body.

h. After the patient has been turned, check the placement of the supporting pillows. Be sure that there are no gaps between pillows. When the patient is turned to the prone position, place a pillow under the lower legs to allow the feet to rest in the position of function and avoid having the toes pushed against the mattress.

i. Position a pillow under the patient's head and shoulders and be sure to place the call bell within his reach.

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1-24. PATIENT CARE AFTER CAST REMOVAL

a. After a cast has been removed, continue to provide support to joints and normal body curves. The muscles will have become weakened from disuse and, although movement is encouraged, support is necessary. Use firm pillows to support the patient while in bed and use elastic bandages or an arm sling, if necessary, when the patient is up and about.

b. Avoid vigorous attempts to remove skin exudate and crusts of dead skin cells, which are present when a cast has been in place for several weeks. Gentle soaking and applications of oil to soften the skin and loosen crusts may be recommended.

c. After the cast is removed, the physician or physical therapist may prescribe exercises to increase strength. If the patient has been doing isometric muscle contractions, he will not have to "relearn" to contract his muscles and will progress more rapidly through rehabilitation. Atrophy of the part may be noticed, but this should gradually disappear with the return of muscle function. Swelling may develop for a while, but decreases with improved muscle tone and circulation as the patient becomes more active.

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1-26. PREPARING THE PATIENT AND HIS UNIT FOR TRACTION

a. There are many local variations in traction procedures, depending upon the preferences of the orthopedic surgeons. The nursing procedures described for the care of patients in traction are only guidelines and are subject to amendment by specific orders of the medical officer. In Department of the Army hospitals, an orthopedic technician usually assists the physician in application of traction. The nursing personnel may be required to assist occasionally, but it is not a nursing responsibility to construct traction. It is a nursing responsibility to recognize and report defects in the traction system so that the defects can be corrected by qualified personnel. The nursing personnel's primary responsibility lies in giving quality nursing care. In order to give effective nursing care to a patient in traction, one should have an understanding of the basic forms of traction and recognize some principle features of standard traction apparatus.

b. Check the physician's orders to determine the type and location of the traction to be applied before you prepare the patient for application of traction.

(1) Remove pajama trousers for application of traction to a lower limb. A towel should be provided for use as a loin-cloth style drape.

(2) Remove pajama coat for application of arm or cervical traction. If a pajama coat is used, it may be worn backward, leaving the affected arm free.

(3) Offer a bedpan or urinal prior to the start of the procedure.

(4) Assemble any equipment or dressing materials that may be needed.

c. Prepare the patient's bed with a firm mattress and a bedboard if one is required. Make the bed with a draw sheet over the bottom linen and fold the top linen back and leave untucked. Depending upon the type of

traction to be applied, assemble the following equipment and complete the bed.

(1) Provide a footboard or sandbags to support the foot that is not in traction. Foot support for the leg in traction is usually provided by means of a footrest, attached when traction is applied.

(2) Attach an overhead Balkan frame with trapeze or an orthopedic head or footboard as appropriate.

(3) Provide several firm, plastic-covered pillows.

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1-27. TRACTION APPARATUS

When working with traction apparatus, the following points should be observed routinely and any defect reported to the charge nurse.

a. Weights. The weights must hang free. Each weight bag must be tied securely to its rope. Avoid bumping or knocking the weight bags. They should not be allowed to swing back and forth. Weights should never be removed from a patient with a fracture unless so ordered by the physician or in the case of an extreme emergency. Weight and pulley traction is applied to provide constant corrective extension. If the weights are removed, the purpose of their use has been defeated.

b. Ropes. There should be no frayed spots or knots in the running length. They should not drag on the bedclothes or the bed frame. No ropes should rest against one another.

c. Pulleys. The rope should rest securely in the pulley grooves. Pulley clamps must be securely attached to the bed frame and must not be moved unless ordered by the physician.

d. Spreader Bars. The spreader bars should cause no pressure on adjacent skin areas.

e. Footplate. The footplate should maintain and support the foot in a neutral position, with no pressure on either side of the foot, the heel, or the toes. It must not rest against the foot of the bed, as this interferes with the traction pull.

f. Trapeze. The trapeze should be suspended from the overhead bar of the bed frame so that the patient can reach and grasp it without strain and without twisting out of proper alignment.

g. Hammocks, Slings, and Halters. These should be free of wrinkles and cause no pressure on bony prominence or joints. If padding material is used, it must be clean, dry, and free of wrinkles and crumbs.

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1-34. SKELETAL TRACTION

a. Skeletal traction is used most frequently in the treatment of fractures of the femur, the tibia, the humerus, and the cervical spine. The traction is applied directly to the bone by use of a metal pin or wire inserted into or through the bone or by tongs inserted into the skull. The pin, wire, or tong is then attached to the traction apparatus.

b. A significant problem with skeletal traction is the potential for infection, which could develop in or around the insertion site. The site must be inspected daily for drainage and odor. Daily cleaning and dressing changes may be prescribed by the physician or by local standing operating procedures.

c. The insertion of pins, wires, or tongs is often done in the operating room under anesthesia. Frequently, the patient will arrive on the ward with most of the traction apparatus already in place. Assist the physician or the orthopedic technician with positioning of the patient and arrangement of the traction apparatus. Because of

differences in age, weight, body type, and the nature of the fracture itself, no two fractures can be considered alike and each patient will require individualized treatment. Therefore, traction procedures are modified for the requirements of each patient. It is extremely important that nursing personnel understand the nature of the traction in use and the patient movement that is permissible while still maintaining the desired traction pull. These factors will affect the planning of basic nursing care for that patient. The following paragraphs discuss several of the most commonly used forms of skeletal traction.

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1-37. SKELETAL TRACTION FOR THE FEMUR

a. The combination of skeletal traction and balanced suspension is widely used for the treatment of fractures of the femoral shaft (see figure 1-16). This method of treatment provides considerable freedom of body movement while maintaining efficient traction on the injured limb. The Thomas leg splint and Pearson attachment are used to achieve this balanced suspension traction.

Figure 1-16. Balanced suspension traction.

b. The Thomas splint (half ring) is applied in various ways: with the ring fitted posteriorly against the ischium or anteriorly in the groin. The thigh rests in a canvas or bandage-strip sling with the popliteal space left free. The leather ring should not be wrapped or padded. If kept smooth, dry, and polished, the leather of the ring is designed to rest against the skin and resist moisture.

c. The Pearson attachment is attached by clamps to the Thomas splint at knee level. A canvas or bandage-strip sling supports the lower leg and provides the desired degree of knee flexion. A footplate is attached to the distal end of the Pearson attachment to support the foot in a neutral position. The heel should be left free.

d. The traction is in line with the long axis of the femoral shaft and is maintained by the rope, pulley, and weights attached to the skeletal tractor, which is fitted onto the wire or pin. Counter traction and balanced

suspension are provided by the ropes, pulleys, and weights attached to the Pearson attachment. When all is operational, the thigh and Thomas splint will be suspended at about a 45° angle with the bed and the lower leg and Pearson attachment will be suspended horizontal to the mattress. The patient may sit up, turn toward the traction side, and raise his hips above the bed by means of the trapeze and still maintain the line of traction.

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