Immobilization and treatment techniques
Elastic bandages
An elastic bandage, a roller bandage, is sometimes called an ACE wrap, ACE bandage, and compression wrap. Besides being used as a bandage over a wound, an elastic bandage is used to limit swelling (edema) in the injured or operative extremity. Commonly, elastic bandages are used for sprains and can restrict movement and provide support to an extremity. Special skill is required to apply elastic bandages properly. Different wrap techniques can be used when applying the elastic bandage. Bandages that are too loose fall off, and those that are too tight can compromise circulation and further harm the patient. It takes practice and attention in order to apply bandages correctly.
Bandaging techniques
Before beginning the bandaging process, the medical assistant must select the correct size bandage if it is not indicated by the provider. Usually for older teens and adults, a 2-inch-wide elastic bandage is used for the hand; a 3-inch-wide bandage is used for the forearm, arm, and lower leg; and a 4 to 6-inch-wide bandage is used for the thigh. The extremity should be clean and dry. During the bandaging process, the body part should be positioned in a normal resting position (position of function). As the bandage is applied, ensure it is smooth and free of wrinkles.
Start the wrapping at the distal end of the extremity, moving proximally. Leave the fingers or toes exposed for circulation checks. Check the circulation below the bandage. Loosen the bandage if the circulation is impaired.
Several bandaging techniques can be used:
- Anchor technique: used at the beginning of the bandaging procedure to secure the elastic bandage (see the worked example below).
- Circular technique: Can be used at the beginning of the bandaging procedure in place of the anchor technique and is most commonly used at the end of the procedure to secure the bandage before applying tape, clips, or the Velcro. Roll the elastic bandage over the affected area in a circular motion. The second and subsequent layers should overlap the previous layer completely.
Three more techniques all start with the anchor or circular technique and finish by securing the bandage with a circular technique. What differs between them is the wrap pattern in between:
- Spiral technique: used to cover the arm or leg. Wrap the limb in a spiral, with each new layer covering about one-third of the previous layer.
- Spiral reverse technique: used to cover the arm or leg. Wrap in a spiral for four turns, then fold the bandage downward onto itself so the upper edge lies parallel to, and overlaps two-thirds of, the previous turn.
- Figure-eight technique: used to support and limit joint movement. Wrap below the joint, diagonally up and across it, then above the joint and diagonally back down, crossing the first pass to form a figure eight; each pass overlaps two-thirds of the previous layer.
Example: Applying the anchor technique
- Place the end of the bandage at an angle on the extremity.
- Wrap the bandage around the limb twice; the angled edge forms a small triangle.
- Fold the triangle’s corner over the second turn.
- Wrap the bandage around the limb a third time, covering the folded corner to lock it in place.
Splints
Splints are temporarily applied to immobilize joints and bones after injury or surgery. The splint can be adjusted as the swelling changes. It provides partial protection while the site heals.
A splint consists of a strip of rigid material that immobilizes an extremity. Custom-designed and ready-made splints are used in the ambulatory care environment. Custom-designed splints commonly use a strip of fiberglass as the rigid material. The fiberglass is held in place by elastic bandages (e.g., ACE bandages). The medical assistant can help the provider apply custom-designed splints. Ready-made splints usually have Velcro straps, which help when taking off or putting on the splints.
Immobilizers, braces, and ankle boots
Immobilizers, braces, and ankle boots are usually used after an injury or surgery. The terms immobilizer and brace are often used interchangeably, but they describe different devices:
An ankle boot (also called a moon boot or walker boot) is a rigid, removable boot. It is used to protect and stabilize the ankle and lower leg after an injury or surgery. These boots can be used for partial, full, or non-weight-bearing extremities.
Slings
A sling is a device used to support and immobilize an injured part of the body, such as the arm, wrist, or shoulder. A sling is often used to help support the arm if a person has an arm casted. A sling can help keep the hand elevated to reduce swelling in the hand and fingers. Slings come in adult and pediatric sizes. If the sling is too loose, it may place stress and strain on the arm. The elbow should be kept at a 90-degree angle. If the sling is too tight, it can compromise or restrict circulation. The patient may have numbness, tingling, or swelling in the hand. The fingers and hand may be blue and cool to the touch.
Casts
Casts are applied to immobilize joints and bones after injury or surgery and provide additional protection. Casts are made from fiberglass or plaster:
- Fiberglass: colorful, lightweight, durable, and porous; x-rays penetrate it better than plaster, so fiberglass casts don’t need to be removed for x-rays.
- Plaster: cheaper and easier to shape.
The medical assistant can help the provider apply the cast. Whether an MA may apply or remove a cast is governed by state law and the state medical board’s scope-of-practice rules, not just the clinic’s job description.
Casts applied in ambulatory care facilities are usually either long or short casts:
- A short arm cast extends from the palm to just before the elbow.
- A long arm cast extends from the palm to the mid-upper arm.
- A short leg cast extends from the foot to just before the kneecap (patella).
- A long leg cast extends from the foot to the mid-thigh.
Extremity casts do not cover the fingers or toes because it is important to check circulation.
During the fiberglass cast application, the medical assistant assembles the supplies and assists the provider with the application.
Patient coaching on CMST
The medical assistant needs to provide cast care instructions to patients. It is important to teach patients about checking the CMST and comparing the casted extremity with the unaffected extremity. Here is what CMST stands for:
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Color: The color of the extremity and nail beds should match those of the opposite extremity. It should be pink. The patient should contact the provider if the toes or fingers are bluish or pale.
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Motion: Being able to move the toes and fingers of the casted extremity is normal. There should be no swelling. Patients should contact the provider if they are unable to move the toes or fingers or if swelling occurs in the fingers and toes.
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Sensation: Normal sensation should be intact. The person should be able to feel light touch on the fingers or toes. Patients should contact the provider if they notice any of the following:
- An increased pain, burning, stinging, or numbness in the toes or fingers
- A “sleeping” or pins-and-needles sensation
- An inability to feel light touch on the toes or fingers
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Temperature: The temperature of the toes or fingers on the casted extremity should match that of the opposite extremity. The fingers or toes should be warm. The patient should contact the provider if the fingers or toes are cooler than those of the opposite extremity.
Any suspicious abnormal findings should be reported to the provider immediately.
Patient coaching on cast care
It is important for the patient to learn how to care for the cast and the extremity:
- Elevate and place dry cold packs on the casted extremity as indicated by the provider. Usually, this is done for the first 24 hours after an injury.
- Continue to move the fingers or toes, which helps to return the blood to the heart and to reduce the swelling.
- Keep the cast clean and dry. Contact the provider if the cast becomes smelly, moldy, or if drainage is noted.
- Cover the cast with a plastic bag prior to bathing or showering. If the fiberglass cast gets wet, use a hair dryer on a cool setting to dry it.
- Avoid putting weight or pressure on the cast.
- Do not put anything inside the cast, including sharp objects, powder, or lotion.
- A metal file can be used to smooth down rough sections of a fiberglass cast. Pad the rough areas to protect the skin.
- A sling can be used to support a casted arm.
Removing casts
The medical assistant can remove casts in the ambulatory care facility. During the removal procedure, the medical assistant should provide adequate support for the extremity. Once the cast is off, the extremity should be washed with a mild soap and warm water, then dried. Skin lotion can be applied. This might be done in the ambulatory care facility or can be done at home.
The medical assistant must coach the patient prior to the cast removal that the extremity may look different. The skin may be dry and flaky. The extremity may be smaller and weaker than the other side. The patient may have some discomfort in the bones and joints that were immobilized. Sometimes patients will need physical therapy to help regain strength and movement in the affected side.