ORTHOPEDIC NURSING: ASSISTIVE DEVICES FOR WALKING, CASTS, AND TRACTION CARE 1.

Describe these assistive devices for walking: a. Cane - The cane or walking stick is the simplest form of walking aid. It is held in the hand and transmits loads to the floor through a shaft. The load which can be applied through a cane is transmitted through the user's hands and wrists and limited by these. b. Walker - A walker (also known as a Zimmer frame) is the most stable walking aid and consists of a freestanding metal framework with three or more points of contact which the user places in front of them and then grips during movement. The points of contact may be either fixed rubber ferrules as with crutches and canes, or wheels, or a combination of both. Wheeled walkers are also known as rollators. c. Crutches - A crutch also transmits loads to the ground through a shaft, but has two points of contact with the arm, at the hand and either below the elbow or below the armpit. This allows significantly greater loads to be exerted through a crutch in comparison with a cane. i. 4 point alternate gait - A slow but stable gait which can be used by any individual able to move each leg separately and bear considerable weight on each foot. Sequence: right crutch, left foot; left crutch, right foot. ii. 2 point alternate gait - Slightly faster than a 4-point gait but requires more balance. This type of gait most closely resembles normal walking. Sequence: right crutch and left foot; left crutch and right foot. iii. 3 point alternate gait - Fairly rapid but requires arm strength to support significant body weight and maintain balance. Sequence: both crutches and the weaker leg move forward simultaneously; then the stronger extremity is moved forward while placing most of the body weight on the arms. iv. Swing-to gait - Faster than any gait above, swing-to is the normal progression to swing-through gait. The movement of the legs is parallel

and this type of gait requires considerable arm and upper body strength to support the entire body weight. Sequence: bear weight on good leg (or legs); advance both crutches forward simultaneously, lean forward while swinging the body to a position even with the crutches. v. Swing-through gait - The fastest of all crutch gaits. Commonly used by runners, swing-through is different from swing-to only in that the body lands past the crutches with every step. Sequence: advance both crutches forward; lift legs off the ground and swing forward landing in advance of the crutches; bring crutches forward rapidly. vi. Stairs 1. Up Walk close to the first stair and hold onto the stair rail. Hold onto the rail with one hand and the crutch with the other hand. Push down on the stair rail and the crutch and step up with the "good" leg. If not allowed to place weight on the "bad" leg, hop up with the "good" leg. Bring the "bad" leg and the crutches up beside the "good" leg. Remember, the "good" leg goes up first and the crutches move with the "bad" leg. 2. Down Walk to the edge of the stairs in the same way. Place the "bad" leg and the crutches down on the step below; support weight by leaning on the crutches and the stair rail. Bring the "good" leg down.

Remember the "bad" leg goes down first and the crutches move with the "bad" leg. Use the same rules when going up and down curbs or doorsteps.

2. Care of client with casts: a. Dos Do keep the cast dry. Water will soften the plaster/fiberglass and cause the cast to lose its shape. Do cover the cast with a plastic bag in wet weather. Stay away from wet grass. Do keep the cast clean. This prevents the cast from breaking down. Stay away from sand and dirt. Do keep a new cast open to air until dry (usually 24 to 48 hours). Do protect a new cast until dry. Do exercise joints by moving all joints not immobilized by the cast. Do keep the edges of the cast smooth. Rough or uneven edges may irritate the skin. Cover rough edges of the cast with adhesive tape. Do avoid breaking or denting the cast. Do elevate the arm or leg on pillows--especially if there is mild swelling. Do keep the bar in between the legs at all times. b. Donts Do not place objects under the cast. Pennies, toys, and small objects will cause sores. Do not scratch. Coat hangers, back scratchers, or pencils under the cast will cause sores. Do not remove padding. Padding helps protect skin and hold the broken bone in place. 3. Care of client with traction: a. Skin

i. Bucks - This is straight traction to one leg, and is often used in cases of hip fractures, or knee injuries. Trac-tion is applied by applying the tubular stockinette to the leg from just below the knee to the ankle, securing it in place with circumferential wrapping, and then applying a spreader block or wire distally, connected to a rope. Sometimes longitudinal strips of tape are applied to the stockinette and traction is applied to the tape strips. The rope is ideally passed through a pulley at the end of the bed, and connected to a 5-8 pound weight. If no pulley is available, one can simply use the foot of the bed, or a smooth round rod between two chairs, over which to pass the rope. Caution is necessary to see that the traction does not pull the heel down against the bed, as this will result in a bedsore behind the heel. These are very difficult to treat! Be certain to assess the circulation after application of the traction, and check it daily. ii. Russells - This is an extremely useful form of traction, utilizing a system of pulleys to result in a strong traction force without over-tracting the skin. The resultant or vector force between the upward traction and the longitudinal traction is about double the weight applied. Here it is absolutely necessary to use a spreader bar on the sling above the knee, to avoid a constrictive force around the distal thigh. iii. Bryant - This is sometimes used in small children with femur fractures, applying Buck's-type traction to both legs in an upward direction. This pulls the legs straight up, with the hips flexed 90 degrees. Great caution must be exercised in using this form of traction on other than very small children, weighing less than 30 pounds. The circumferential wrapping, together with the elevated position, may cause ischemia to the leg or foot, which can be disastrous! Enough traction is applied to just lift the buttocks off the bed. iv. Cervical - 5-6 pounds of continuous cervical traction can be tolerated via a traction sling beneath the occiput and beneath the chin. This sling should be padded well. In cases of cervical fracture the traction must be in line

with the trunk (axial). In cases of suspected herniated cervical discs, the traction should be in about 20-30 degrees upward angulation. v. Pelvic - Pelvic traction may be used for herniated lumbar discs. In this case the traction should be applied in about 30 to 45 degrees upward direction. This reverses the lumbar lordotic curve, opening the posterior part of the intervertebral disc space. Pelvic traction may also be used in some cases of spinal fractures. b. Skeletal i. Balance-Suspension - 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 fi tted 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 opera tional, 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 matt ress. The patient may sit up, turn toward the traction side, and raise his hips above th e bed by means of the trapeze and still maintain the line of traction ii. Thomas splint - applied in various ways: with the ring fitted posteriorly against the ischium or anteriorly in the groin. The thigh rests in a canvas or bandagestrip 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 ri ng is designed to rest against the skin and resist moisture. iii. Pearson attachment - attached by clamps to the Thomas splint at knee level. A canvas or bandagestrip sling supports the lower leg and provides the desired degree of knee flexion. A footplate is attached to the distal end of the Pear

son attachment to support the foot in a neutral position. The heel should be left free. iv. Principles of care

References:
http://en.wikipedia.org/wiki/Mobility_aid http://www.walkeasy.com/interact/crutch_gait2.asp http://www.lpch.org/DiseaseHealthInfo/HealthLibrary/orthopaedics/crutch.html http://www.uchicagokidshospital.org/specialties/orthopaedics/patient-guides/casts.html http://www.christianorthopedicpartners.org/jungleortho/monograph1.htm http://armymedical.tpub.com/md0916/md09160040.htm