Who was the first to use a plaster cast? History of the plaster cast
97. Plaster and plaster casts. Plaster bandages, splints. Basic types and rules for applying plaster casts.
Plaster casts are widely used in traumatology and orthopedics and are used to hold fragments of bones and joints in their given position.
Medical gypsum is a semi-aqueous calcium sulfate salt, available in powder form. When combined with water, the hardening process of the gypsum begins after 5–7 minutes and ends after 10–15 minutes. The plaster gains full strength after the entire bandage has dried.
Using various additives you can speed up or, conversely, slow down the hardening process of gypsum. If the plaster does not harden well, it must be soaked in warm water (35–40 °C). You can add aluminum alum to the water at the rate of 5–10 g per 1 liter or table salt (1 tablespoon per 1 liter). A 3% starch solution and glycerin delay the setting of gypsum.
Since gypsum is very hygroscopic, it is stored in a dry, warm place.
Plaster bandages are made from ordinary gauze. To do this, the bandage is gradually unwound and a thin layer of gypsum powder is applied to it, after which the bandage is again loosely rolled into a roll.
Ready-made non-shedding plaster bandages are very convenient for use. The plaster cast is intended to perform the following manipulations: pain relief for fractures, manual reposition of bone fragments and reposition using traction devices, application of adhesive traction, plaster and adhesive dressings. In some cases, it is permissible to apply skeletal traction.
Plaster bandages are immersed in cold or slightly warmed water, and air bubbles that are released when the bandages get wet are clearly visible. At this point, you should not press on the bandages, as part of the bandage may not be saturated with water. After 2–3 minutes, the bandages are ready for use. They are taken out, lightly wrung out and rolled out on a plaster table, or the damaged part of the patient’s body is directly bandaged. To make the bandage strong enough, you need at least 5 layers of bandage. When applying large plaster casts, you should not soak all the bandages at once, otherwise the nurse will not have time to use some of the bandages within 10 minutes, they will harden and will be unsuitable for further use.
Rules for applying bandages:
– before rolling out the plaster, measure the length of the applied bandage along the healthy limb;
– in most cases, the bandage is applied with the patient lying down. The part of the body on which the bandage is applied is raised above the table level using various devices;
– plaster cast should prevent the formation of stiffness in joints in a functionally unfavorable (vicious) position. To do this, the foot is placed at a right angle to the axis of the shin, the shin is in a position of slight flexion (165°) at the knee joint, the thigh is in a position of extension in the hip joint. Even with the formation of contracture in the joints lower limb in this case it will be supportive and the patient will be able to walk. On upper limb the fingers are placed in a position of slight palmar flexion with the first finger opposed, the hand is in a position of dorsal extension at an angle of 45° in the wrist joint, the flexor forearm is at an angle of 90-100° in the elbow joint, the shoulder is abducted from the body at an angle of 15–20° at using a cotton-gauze roll placed in armpit. For some diseases and injuries, as directed by the traumatologist, a bandage may be applied in the so-called vicious position for a period of no more than one and a half to two months. After 3–4 weeks, when initial consolidation of the fragments appears, the bandage is removed, the limb is placed in the correct position and fixed with a plaster;
– plaster bandages should lie evenly, without folds or kinks. Anyone who does not know desmurgy techniques should not apply plaster casts;
– areas subject to the greatest load are additionally strengthened (joint area, sole of the foot, etc.);
– peripheral section limbs (toes, hands) are left open and accessible for observation in order to notice symptoms of compression of the limb in time and cut the bandage;
– before the plaster hardens, the bandage must be well modeled. By stroking the bandage, the body part is shaped. The bandage must be an exact cast of this part of the body with all its protrusions and depressions;
– after applying the bandage, it is marked, i.e., the diagram of the fracture, the date of the fracture, the date of application of the bandage, the date of removal of the bandage, and the name of the doctor are applied to it.
Methods of applying plaster casts. According to the method of application, plaster casts are divided into lined and unlined. With padding, a limb or other part of the body is first wrapped in a thin layer of cotton wool, then plaster bandages are placed on top of the cotton wool. Unlined dressings are applied directly to the skin. Pre-bone protrusions (area of the ankles, femoral condyles, iliac spines, etc.) are isolated with a thin layer of cotton wool. The first bandages do not compress the limb and do not cause bedsores from the plaster, but they do not fix bone fragments firmly enough, so when they are applied, secondary displacement of the fragments often occurs. Unlined bandages, if not carefully observed, can cause compression of the limb to the point of necrosis and pressure sores on the skin.
According to their structure, plaster casts are divided into longitudinal and circular. A circular plaster cast covers the damaged part of the body on all sides, while a splint cast covers only one part. A variety of circular dressings are fenestrated and bridge-like dressings. A windowed bandage is a circular bandage in which a window is cut out over a wound, fistula, drainage, etc. Care must be taken that the edges of the plaster in the area of the window do not cut into the skin, otherwise when walking soft fabrics will swell, which will worsen the wound healing conditions. Protrusion of soft tissues can be prevented by covering the window with a plaster flap each time after dressing.
A bridge bandage is indicated in cases where the wound is located throughout the entire circumference of the limb. First, circular bandages are applied proximally and distally to the wound, then both bandages are connected to each other with U-shaped curved metal stirrups. When connected only with plaster bandages, the bridge is fragile and breaks due to the weight of the peripheral part of the bandage.
Bandages applied to various parts of the body have their own names, for example, corset-coxite bandage, “boot”, etc. A bandage that fixes only one joint is called a splint. All other bandages must ensure immobility of at least 2 adjacent joints, and the hip bandage – three.
A plaster cast on the forearm is most often applied to fractures of the radius in a typical location. The bandages are laid out evenly over the entire length of the forearm from elbow joint to the base of the fingers. A plaster splint for the ankle joint is indicated for fractures of the lateral malleolus without displacement of the fragment and ruptures of the ankle ligaments. Plaster bandages are rolled out with gradual expansion at the top of the bandage. The length of the patient’s foot is measured and, accordingly, 2 cuts are made on the splint in the transverse direction at the bend of the bandage. The splint is modeled and strengthened with a soft bandage. Splints are very easy to turn into circular bandages. To do this, it is enough to strengthen them on the limb not with gauze, but with 4–5 layers of plaster bandage.
A lining circular plaster cast is applied after orthopedic operations and in cases where bone fragments are welded together by callus and cannot move. First, the limb is wrapped in a thin layer of cotton wool, for which they take gray cotton wool rolled into a roll. It is impossible to cover it with separate pieces of cotton wool of different thicknesses, since the cotton wool will become matted and the bandage will cause a lot of inconvenience to the patient when wearing it. After this, a circular bandage in 5–6 layers is applied over the cotton wool with plaster bandages.
Removing the plaster cast. The bandage is removed using plaster scissors, a file, plaster forceps and a metal spatula. If the bandage is loose, you can immediately use plaster scissors to remove it. In other cases, you must first insert a spatula under the bandage in order to protect the skin from cuts from the scissors. The bandages are cut on the side where there is more soft tissue. For example, a circular bandage up to the middle third of the thigh - along the posterior outer surface, a corset - on the back, etc. To remove the splint, it is enough to cut the soft bandage.
Did you know that...
The invention and widespread introduction into medical practice of a plaster cast for bone fractures is one of most important achievements surgery of the last century. And it was N.I. Pirogov was the first in the world to develop and put into practice a fundamentally new way bandages soaked in liquid plaster.
It cannot be said that before Pirogov there were no attempts to use gypsum. The works of Arab doctors, the Dutchman Hendrichs, the Russian surgeons K. Gibenthal and V. Basov, the Brussels surgeon Seten, the Frenchman Lafargue and others are well known. However, they did not use a bandage, but a plaster solution, sometimes mixing it with starch and adding blotting paper to it.
An example of this is the Basov method, proposed in 1842. The patient's broken arm or leg was placed in a special box filled with alabaster solution; the box was then attached to the ceiling through a block. The victim was essentially bedridden.
In 1851, the Dutch doctor Matthiessen already began using a plaster cast. He rubbed strips of cloth with dry plaster, wrapped them around the injured limb, and only then moistened them with water.
To achieve this, Pirogov is trying to use various raw materials for dressings - starch, gutta-percha, colloidin. Convinced of the shortcomings of these materials, N.I. Pirogov proposed his own plaster cast, which is still used almost unchanged today.
The fact is that gypsum is precisely the most best material, the great surgeon became convinced after visiting the workshop of the then famous sculptor N.A. Stepanov, where “... for the first time I saw... the effect of a gypsum solution on canvas. I guessed,” writes N.I. Pirogov, “that it could be used in surgery, and immediately applied bandages and strips of canvas soaked in this solution , for a complex fracture of the leg. The success was remarkable. The bandage dried out in a few minutes: an oblique fracture with severe bleeding and perforation of the skin... healed without suppuration... I was convinced that this bandage could find great application in military field practice, and therefore published a description of my method."
Pirogov first used a plaster cast in 1852 in a military hospital, and in 1854 in the field, during the defense of Sevastopol. The widespread use of the bone immobilization method he created made it possible to carry out, as he called, “saving treatment”: even with extensive bone damage, not to amputate, but to save the limbs of many hundreds of wounded people.
Proper treatment of fractures, especially gunshot fractures, during the war, which N.I. Pirogov figuratively called it a “traumatic epidemic,” which was the key to not only preserving a limb, but sometimes even the life of the wounded.
Portrait of N.I. Pirogov by artist L. Lamm
One of the most important inventions of the brilliant Russian doctor, who was the first to use anesthesia on the battlefield and brought nurses into the army
Imagine an ordinary emergency room - say, somewhere in Moscow. Imagine that you find yourself there not for personal reasons, that is, not with an injury that distracts you from any extraneous observations, but as a random passerby. But - with the opportunity to look into any office. And so, walking along the corridor, you notice a door with the inscription “Gypsum”. And what's behind it? Behind her is a classic medical office, the appearance of which differs only from the low square bathtub in one of the corners.
Yes, yes, this is the same place where, on a broken arm or leg, after initial examination a traumatologist and an x-ray taken, a plaster cast will be applied. For what? So that the bones grow together as they should, and not at random. And so that the skin can still breathe. And so as not to disturb the broken limb with a careless movement. And... Why ask! After all, everyone knows: if something is broken, it is necessary to apply a plaster cast.
But this “everyone knows” is at most 160 years old. Because for the first time a plaster cast was used as a means of treatment in 1852 by the great Russian doctor, surgeon Nikolai Pirogov. No one in the world had done anything like this before. Well, after it, it turns out, anyone can do it, anywhere. But the “Pirogov” plaster cast is precisely that priority that is not disputed by anyone in the world. Simply because it is impossible to dispute the obvious: the fact that gypsum is like medical product- one of the purely Russian inventions.
Portrait of Nikolai Pirogov by artist Ilya Repin, 1881.
War as an engine of progress
Back to top Crimean War Russia turned out to be unprepared in many ways. No, not in the sense that she did not know about the coming attack, like the USSR in June 1941. In those distant times, the habit of saying “I’m going to attack you” was still in use, and intelligence and counterintelligence were not yet so developed as to carefully conceal preparations for an attack. The country was not ready in the general, economic and social sense. There was not enough modern, modern fleet, railways(and this turned out to be critical!) leading to the theater of military operations...
And also in Russian army there were not enough doctors. By the beginning of the Crimean War, the organization of medical service in the army was in accordance with the manual written a quarter of a century earlier. According to his requirements, after the outbreak of hostilities, the troops should have had more than 2,000 doctors, almost 3,500 paramedics and 350 paramedic students. In reality, there was no one enough: neither doctors (a tenth part), nor paramedics (a twentieth part), and their students were not there at all.
It would seem that there is not such a significant shortage. But nevertheless, as military researcher Ivan Bliokh wrote, “at the beginning of the siege of Sevastopol, there was one doctor for every three hundred wounded people.” To change this ratio, according to historian Nikolai Gübbenet, during the Crimean War more than a thousand doctors were recruited into service, including foreigners and students who received a diploma but did not complete their studies. And almost 4,000 paramedics and their students, half of whom were disabled during the fighting.
In such a situation and taking into account, alas, the rear organized disorder inherent, alas, in the Russian army of that time, the number of wounded who were permanently incapacitated should have reached at least a quarter. But just as the resilience of the defenders of Sevastopol amazed the allies who were preparing for a quick victory, the efforts of the doctors unexpectedly gave a much better result. A result that had several explanations, but one name - Pirogov. After all, it was he who introduced immobilizing plaster casts into the practice of military field surgery.
What did this give the army? First of all, it is an opportunity to return to duty many of those wounded who, a few years earlier, would have simply lost an arm or leg as a result of amputation. After all, before Pirogov this process was arranged very simply. If a person came to the surgeons table with an arm or leg broken by a bullet or shrapnel, he most often faced amputation. For soldiers - according to the decision of doctors, for officers - based on the results of negotiations with doctors. Otherwise, the wounded man would still most likely not return to duty. After all, the unfixed bones grew together haphazardly, and the person remained crippled.
From the workshop to the operating room
As Nikolai Pirogov himself wrote, “war is a traumatic epidemic.” And like any epidemic, a war had to find its own, figuratively speaking, vaccine. This - partly because not all wounds are limited to broken bones - was plaster.
As often happens with brilliant inventions, Dr. Pirogov came up with the idea of making his immobilizing bandage literally from what was lying under his feet. Or rather, at hand. Because the final decision to use plaster of Paris, moistened with water and fixed with a bandage, for the bandage came to him in... the sculptor’s workshop.
In 1852, Nikolai Pirogov, as he himself recalled a decade and a half later, watched the sculptor Nikolai Stepanov work. “For the first time I saw... the effect of a gypsum solution on a canvas,” the doctor wrote. “I guessed that it could be used in surgery, and immediately applied bandages and strips of canvas soaked in this solution to a complex fracture of the tibia. The success was remarkable. The bandage dried in a few minutes: an oblique fracture with strong bleeding and perforation of the skin... healed without suppuration and without any seizures. I was convinced that this bandage could find great application in military field practice.” Which is exactly what happened.
But Dr. Pirogov’s discovery was not only the result of an accidental insight. Nikolai Ivanovich struggled with the problem of a reliable fixation bandage for many years. By 1852, Pirogov already had experience in using linden splints and starch dressings. The latter was something very similar to a plaster cast. Pieces of canvas soaked in a starch solution were placed layer by layer on the broken limb - just like in the papier-mâché technique. This process was quite long, the starch did not harden immediately, and the dressing turned out to be bulky, heavy and not waterproof. In addition, it did not allow air to pass through well, which negatively affected the wound if the fracture was open.
By the same time, ideas using gypsum were already known. For example, in 1843, thirty-year-old doctor Vasily Basov proposed fixing a broken leg or arm with alabaster poured into a large box - a “dressing projectile.” Then this box was raised on blocks to the ceiling and secured in this position - almost the same way today, if necessary, plastered limbs are secured. But the weight was, of course, prohibitive, and there was no breathability.
And in 1851, the Dutch military doctor Antonius Mathijsen introduced into practice his own method of fixing broken bones using bandages rubbed with plaster, which were applied to the fracture site and moistened with water right there. He wrote about this innovation in February 1852 in the Belgian medical journal Reportorium. So the idea in the full sense of the word was in the air. But only Pirogov was able to fully appreciate it and find the most convenient way of plastering. And not just anywhere, but in war.
“Safety benefit” in Pirogov style
Let's return to besieged Sevastopol, during the Crimean War. The already famous surgeon Nikolai Pirogov arrived at it on October 24, 1854, at the very height of the events. It was on this day that the notorious Battle of Inkerman took place, which ended in a major failure for the Russian troops. And here are the shortcomings of the organization medical care they showed themselves to the fullest in the troops.
Painting “The Twentieth Infantry Regiment at the Battle of Inkerman” by artist David Rowlands. Source: wikipedia.org
In a letter to his wife Alexandra on November 24, 1854, Pirogov wrote: “Yes, October 24 was not unexpected: it was foreseen, planned and not taken care of. 10 and even 11,000 were out of action, 6,000 were too wounded, and absolutely nothing was prepared for these wounded; They left them like dogs on the ground, on bunks; for whole weeks they were not bandaged or even fed. The British were reproached after Alma for not doing anything in favor of the wounded enemy; We ourselves did nothing on October 24th. Arriving in Sevastopol on November 12, therefore, 18 days after the case, I found too 2000 wounded, crowded together, lying on dirty mattresses, mixed up, and for 10 whole days, almost from morning to evening, I had to operate on those who should have had the operation immediately after battles."
It was in this environment that Dr. Pirogov’s talents fully manifested themselves. Firstly, it was to him that he was credited with introducing into practice the system of sorting the wounded: “I was the first to introduce the sorting of the wounded at the Sevastopol dressing stations and thereby destroyed the chaos that prevailed there,” the great surgeon himself wrote about this. According to Pirogov, each wounded person had to be classified into one of five types. The first is the hopeless and mortally wounded, who no longer need doctors, but comforters: nurses or priests. The second is seriously and dangerously wounded, requiring immediate assistance. The third is the seriously wounded, “who also require immediate, but more protective benefits.” The fourth is "the wounded for whom immediate surgical care is necessary only to make possible transportation." And finally, the fifth - “slightly wounded, or those for whom the first aid is limited to applying a light bandage or removing a superficially seated bullet.”
And secondly, it was here, in Sevastopol, that Nikolai Ivanovich began to widely use the plaster cast he had just invented. How much importance he attached to this innovation can be judged by a simple fact. It was for him that Pirogov identified a special type of wounded - those requiring “safety benefits.”
How widely the plaster cast was used in Sevastopol and, in general, in the Crimean War can only be judged by indirect signs. Alas, even Pirogov, who meticulously described everything that happened to him in Crimea, did not bother to leave it for posterity exact information on this score - mainly value judgments. Shortly before his death, in 1879, Pirogov wrote: “I first introduced the plaster cast into military hospital practice in 1852, and into military field practice in 1854, finally... took its toll and became a necessary accessory to field surgical practice. I allow myself to think that my introduction of a plaster cast into field surgery mainly contributed to the spread of cost-saving treatment in field practice.”
Here it is, that very “saving treatment”, it is also a “preventive benefit”! It was for this purpose that what Nikolai Pirogov called “a molded alabaster (plaster) bandage” was used in Sevastopol. And the frequency of its use directly depended on how many wounded the doctor tried to protect from amputation - which means how many soldiers needed to have plaster applied to gunshot fractures of their arms and legs. And apparently they numbered in the hundreds. “We suddenly had up to six hundred wounded in one night, and we performed too many seventy amputations in twelve hours. These are repeated incessantly in various sizes,” Pirogov wrote to his wife on April 22, 1855. And according to eyewitnesses, the use of Pirogov’s “stick-on bandage” made it possible to reduce the number of amputations several times. It turns out that only on that terrible day that the surgeon told his wife about, plaster was applied to two or three hundred wounded people!
Nikolai Pirogov in Simferopol. The artist is unknown.