Immobilization

Definition

Immobilization refers to the process of holding a joint or bone in place with a splint, cast, or brace. This is done to prevent an injured area from moving while it heals.

Purpose

Splints, casts, and braces support and protect broken bones, dislocated joints, and injured soft tissues such as tendons and ligaments. Immobilization restricts motion to allow the injured area to heal. It can help reduce pain , swelling, and muscle spasms . In some cases, splints and casts are applied after surgical procedures that repair bones, tendons, or ligaments. This allows for protection and proper alignment early in the healing process.

Description

When an arm, hand, leg, or foot requires immobilization, the cast, splint, or brace will generally extend from the joint above the injury to the joint below the injury. For example, an injury to the mid-calf requires immobilization from the knee to the ankle and foot. Injuries of the hip and upper thigh or shoulder and upper arm require a cast that encircles the body and extends down the injured leg or arm.

Casts and splints

Casts are generally used to immobilize a broken bone. Once the doctor makes sure the two broken ends of the bone are aligned, a cast is put on to keep them in place until they are rejoined through natural healing. Casts are applied by a physician, a nurse, or an assistant. They are custom-made to fit each person, and are usually made of plaster or fiberglass. Fiberglass weighs less than plaster, is more durable, and allows the skin more adequate airflow than plaster. A layer of cotton or synthetic padding is first wrapped around the skin to cover the injured area and protect the skin. The plaster or fiber-glass is then applied over this and is then allowed to dry. It can take up to 24 hours for a cast to dry completely.

Most casts should be kept dry. However, some types of fiberglass casts use Goretex padding that is waterproof, allowing the cast to be completely immersed in water when taking a shower or bath. There are some circumstances when this type of cast material cannot be used.

A splint is often used to immobilize a dislocated joint while it heals. Splints are also often used for finger injuries, such as fractures or baseball finger. Baseball finger is an injury in which the tendon at the end of the finger is separated from the bone as a result of trauma. Splinting is also used to immobilize an injured arm or leg immediately after an injury. Before moving a child who has injured an arm or leg, some type of temporary splint should be applied to prevent further injury to the area. Splints may be made of acrylic, polyethylene foam, plaster of paris, or aluminum. In an emergency, a splint can be made from a piece of wood or rolled magazine.

Slings

Slings are often used to support the arm after a fracture or other injury. They are generally used along with a cast or splint, but are sometimes used alone as a means of immobilization. They can be used in an emergency to immobilize the arm until a doctor can see the child. A triangular bandage is placed under the injured arm and then tied around the neck.

Braces

Braces are used to support, align, or hold a body part in the correct position. Braces are sometimes used after a surgical procedure is performed on an arm or a leg. They may also be used when an injury has occurred. Since some braces can be easily taken off and put back on, they are often used when the child needs physical therapy or must exercise the limb during the healing process. Many braces can also be adjusted to allow for a certain amount of movement.

Either a custom-made or a ready-made brace can be used. The off-the-shelf braces are made in a variety of shapes and sizes. They generally have Velcro straps that make the brace easy to adjust and to put on and take off. Both braces and splints offer less support and protection than a cast and may not be a treatment option in all circumstances.

Collars

A collar is generally used for neck injuries. A soft collar can relieve pain by restricting movement of the

head and neck. Collars also transfer some of the weight of the head from the neck to the chest. Stiff collars are generally used to support the neck when there has been a fracture in one of the neck bones. Cervical collars are widely used by emergency personnel at the scene of injuries when there is a potential neck or head injury . The collar helps to ensure that the neck and head do not move, which could make the injury worse.

Traction

Immobilization may also be secured by traction. Traction involves using a method for applying tension to correct the alignment of two structures (e.g., two bones) and hold them in the correct position. For example, if the bone in the thigh breaks, the broken ends may have a tendency to overlap. Use of traction will hold them in the correct position for healing to occur. The strongest form of traction involves inserting a stainless steel pin through a bony prominence attached by a horseshoe-shaped bow and rope to a pulley and weights suspended over the end of the patient's bed.

Traction must be balanced by countertraction. This may be obtained by tilting the bed and allowing the patient's body to act as a counterweight. Another technique involves applying weights pulling in the opposite direction.

Traction for neck injuries may be in the form of a leather or cotton cloth halter placed around the chin and lower back of the head. For very severe neck injuries that require maximum traction, tongs that resemble ice tongs are inserted into small holes drilled in the outer skull. All traction requires careful observation and adjustment by doctors and nurses to maintain proper balance and alignment of the traction with free suspension of the weights.

Immobilization can also be secured by a form of traction called skin traction. This is a combination of a splint and traction that is applied to the arms or legs by strips of adhesive tape placed over the skin of the arm or leg. Adhesive strips, moleskin, or foam rubber traction strips are applied on the skin. This method is effective only if a moderate amount of traction is required.

Precautions

It is important to ensure that the cast is not too tight, such that blood flow is cut off and swelling is not restricted.

Preparation

There are many reasons for immobilization using splints, casts, and braces. It can be helpful if the child understands why immobilization is being done, as it may help with compliance.

Aftercare

After a cast or splint has been put on, the injured arm or leg should be elevated for 24 to 72 hours. It is recommended that the child lie or sit with the injured arm or leg raised above the level of the heart. Rest, combined with elevation, will reduce pain and speed the healing process by minimizing swelling.

Fingers or toes can be exercised as much as can be tolerated after casting. This has been found to decrease swelling and prevent stiffness. If excessive swelling is noted, the application of ice to the splint or cast may be helpful.

After the cast, splint, or brace is removed, gradual exercise is usually performed to regain muscle strength and motion. The doctor may also recommend hydrotherapy, heat treatments, and other forms of physical therapy.

Risks

For some children, such as those in traction, immobilization will require long periods of bed rest. Lying in one position in bed for an extended period can result in sores on the skin (decubitus ulcers) and skin infection. Long periods of bed rest can also cause a buildup of fluid in the lungs or an infection in the lungs ( pneumonia ). Urinary infection can also be a result of extended bed rest. Occasionally, blood clots can develop in the injured area.

People who have casts, splints, or braces on their arms or legs will generally spend several weeks not using the injured arm or leg. This lack of use can result in decreased muscle tone and shrinkage of the muscle (atrophy). This loss can usually be regained, however, through rehabilitation after the injury has healed.

Immobility can also cause psychological stress. A child restricted to a bed with a traction device may become frustrated and bored, and perhaps even depressed, irritable, and withdrawn. It may be helpful to have a bed that can be moved more easily than a traditional bed, so that the child can participate in as many family activities (such as dinner time and movie nights) as possible.

There is the possibility of decreased circulation if the cast, splint, or brace fits too tightly. If swelling occurs but the cast is tight enough that the swelling cannot be accommodated, serious complications can occur. Excessive pressure over a nerve can cause irritation or possible damage if not corrected. If the cast, splint, or brace breaks or malfunctions, the healing process of the bone or soft tissue can be disrupted and lead to deformity.

Parental concerns

Children can find immobilization very frustrating. Being restricted from participating in normal activities with friends because of a broken an arm or leg, or having to sit in bed for weeks if significant traction is required can be stressful. Children can be helped if parents try to provide alternate activities and engage the child in as many activities as possible with the family.

Resources

WEB SITES

"Fractures and Sprains: Reference Summary." National Medical Library-National Institutes of Health. 2001. Available online at: http://www.nlm.nih.gov/medlineplus/tutorials/fracturesandsprains/op139101.pdf (accessed October 9, 2004).

"Fractures in Children." Cincinnati Children's Hospital Medical Center. January 2004. Available online at: http://www.cincinnatichildrens.org/health/info/orthopaedics/diagnose/fractures.htm (accessed October 9, 2004).

"Weightlessness, Bed Rest and Immobilization." National Institutes of Health: Osteoporosis and Related Bone Diseases-National Resource Center. August 2001. Available online at: http://www.osteo.org/newfile.asp?doc=r608i&doctype=HTML+Fact+Sheet&doctitle=Weightlessness%2C+Bed+Rest+and+Immobilization (accessed October 9, 2004).

Tish Davidson, A.M.
Jeffrey P. Larson, RPT