AMPUTATIONS

GENERAL Amputation of the limb is one of oldest surgi al pro edures pra tised e!en in prehistori times" E!er# $ar in histor# has meant thousands of limbs lost in the battle or remo!ed after in%ur#" &ith the ad!an es in anaesthesia' blood transfusion and asepti te hni(ue' more and li!es ha!e been sa!ed' lea!ing more and more sur!i!ors $ith loss of limbs" The phenomenal in rease in the road traffi a idents all o!er the $orld has also enormousl# in reased the number of amputations of limbs" Till re entl#' the main aim of amputation $as to sa!e life b# remo!al of a badl# damaged limb or b# eradi ation of a malignant disease" )ollo$ing amputations' some t#pe of artifi ial limb fitting had been pra tised e!en in an ient times" The ma*imum restoration of the lost fun tion of the limb has be ome possible b# the re ent ad!an es in artifiial limb fabri ation and fitting" Amputation surger# is no longer a rude ablational surger# but a refined re onstru ti!e pro edure' to prepare the stump not onl# for its motor fun tions of lo omotion or prehension but for e!en sensor# feed ba + and osmesis" ,en e' it is essential that a surgeon amputating a limb and fashioning the stump must ha!e a good +no$ledge of the prostheti pro edures a!ailable and $or+ in lose oordination as a team $ith the prostheti te hni ian and the ph#siotherapist" Amputation is defined as the surgi al remo!al of a part or $hole of a limb" IN-I.ATIONS The ablation of a limb is an e*treme step and an irre!ersible operation and e!er# are should be ta+en to see that an amputation is done onl# $hen absolutel# indi ated" Amputation should be onsidered onl# if the limb is dead /gengrenous0' d#ing /grossl# is haemi 0' dangerous /due to malignan #0' or dud /useless limb0" The ommon indi ations for amputation in our ountr# are1 2" Traumati onditions1 .rush in%uries to the limb" onditions of the limb"

3" 4as ular onditions1 Is haemi

i0 Thromboangiitis obliterans /5uerger6s -isease0 ii0 Arterios lerosis1 Senile and -iabeti iii0 Gangrene1 -r# and Moist" 7" Neoplasti onditions1 Malignant tumours of bone or soft tissue /Osteosar oma s#no!iosar oma0

8" Infe ti!e onditions1 2" Lepros#1 &hen the leg is totall# useless and grossl# destro#ed 3" A tinom#o osis of the foot or hand 7" )ilarial elephantiasis" 9" .ongenital onditions1 &hen the limb is grossl# deformed and useless" Traumati onditions

In transport and industrial a idents' the limbs $ith se!ere rush in%uries and total loss of blood suppl# often re(uire amputation as a life sa!ing measure" &hen threat to life is not serious' a period of onser!ati!e management of the sho + ma# e!en restore ollateral ir ulation in the limb' help in a!oiding amputation or minimising the segment to be remo!ed" Emergen # repair of torn blood !essels b# the !as ular surgeon an ma+e limbs !iable and e!en help to a!oid amputation" 4as ular onditions Thromboangiitis obliterans /5uerger6s disease0 is !er# ommon in South India" &hen all efforts to relie!e the e* ru iating pain in the patient' ontrol infe tion and to pre!ent gengrene of the limb fail' the patient $ill ha!e to be treated b# amputation at appropriate le!els" The a!erage age of the amputee in India is mu h lo$er than in the &est $here the predominant indi ation is the !as ular insuffi ien # in the geriatri age group" All t#pes of gangrene are indi ations for amputations" Tumours Osteosar oma and soft tissue sar omas in hildren and hondrosar oma and melanomas in the older age group are the ommon indi ations for amputation" The introdu tion of ne$er methods of hemotherap# and immunotherap# ha!e impro!ed the prognosis and sur!i!al rate' in man# ases of malignant tumours" -eformities .ases of gross ongenital deformities of limbs li+e pho omelia $here orre tion is impossible' ha!e to be treated $ith amputation and prostheti fitting" T:PES O) AMPUTATIONS 2" Guillotine Amputation This is an emergen # amputation done as a life sa!ing measure" This is done in ases of gross rush in%uries of the limb" It is also indi ated in ases of gas gangrene' $hen a rapid remo!al of the dangerousl# infe ted part is a life sa!ing pro edure" In

guillotine amputation' the in ision is ir ular around the limb at the site of bone se tion and all the tissues are ut at the same le!el and the $ound is left open to pro!ide free drainage" 3" .lassi al Amputation These are planned amputations $here regular s+in flaps are raised and the $ound is losed after ablation of the limb" 7" Re!ision Amputation Re!ision amputations are done1 a0 As a se ond stage in guillotine amputation" b0 Those $ith !er# unsatisfa tor# stumps follo$ing a pre!ious amputation" SELE.TION O) LE4ELS O) AMPUTATION The lassi al sites of amputation of limbs $ere determined on the basis of the follo$ing onsiderations" 2" The disease pro ess for $hi h the amputation $as done to eradi ate the patholog#" 3" The !as ular suppl# to the s+in flaps" 7" The re(uirements of limb fitting pro edures and te hni(ues a!ailable at that time" Radiograph# of the part is done to see the e*tent of the malignant disease" In some ases arteriograph# ma# be used to assess the !as ularit# of the limb and le!el of !iabilit#" Modern ad!an es in the te hnolog# of limb fitting has made possible satisfa tor# limb fitting to stumps of an# length and hen e one should not sti + to the lassi al le!els too rigidl# and sa rifi e parts of limbs $hi h ould be sa!ed" LE4ELS O) AMPUTATION a0 In the lo$er limb b0 In the upper limb A0 The le!els of amputation in the lo$er limbs are as gi!en belo$" 2" ,ind (uarter amputation" 3" ,ip disarti ulation" 7"" Abo!e +nee amputation" 8" Through +nee disarti ulation"

9" 5elo$ +nee amputation" ;" S#me6s amputation" <" )orefoot amputation" =" Toe amputation" 50 The le!els of amputation in the upper limbs are as follo$s" 2" )ore(uarter amputation" 3" Shoulder disarti ulation" 7" Abo!e elbo$ amputation" 8" Elbo$ disarti ulation" 9" 5elo$ elbo$ amputation" ;" &rist disarti ulation" <" )inger amputation" TE.,NI>UE O) AMPUTATION In all asses of ele ti!e amputations' the patient should be prepared properl#" In addition to the general preparation of the patient and lo al preparation of the part of surger#' the patient should be ph# hologi all# prepared for the mutilation' $ith assuran es that he $ill be restored anatomi all# and fun tionall# to as near normal as possible" Amputation' not onl# mutilates the person ph#si all# but# also multilates the personalit# of the patient" General anaesthesia is preferable in most ases of amputation" The operation is best done in a bloodness field' using pneumati tourni(uet or an Esmar h6s rubber bandage tourni(uet" In the geriatri patient $ith arterios leroti !essels' the tourni(uet might pre ipitate !asospasm and further is hemia of the limb and is better a!oided" 5asi prin iples in Amputation The follo$ing steps are appli able to all le!els of amputation in the limbs" Mar+ out and raise appropriate s+in flaps" .ut mus les and soft tissue 2?3@ pro*imal to s+in se tion" .ut bone 2@ pro*imal to mus le se tion" Identif# blood !essels and ligate" .ut ner!e ends and allo$ them to retra t" Remo!e tourni(uet and obtain hemostasis" Suture the mus les and o!er the bone end" Pla e a drain $ithin the $ound" Suture deep fas ia and s+in" Appl# dressing and ompression bandage" Pro!ide a splint to rest the stump" STUMP AN- ITS MANAGEMENT The Strump is the residual part of the limb left after the amputation" It should not be %ust an anatomi al residue but should be an a ti!e motor organ to mo!e the prosthesis and also gi!e some sensor# feedba +" ,en e' the are of the stump is !er# important to pro!ide good fun tion in the limb" In lo$er limb

amputations' the fun tions to be restored are $eight bearing and lo omotion and sensor# feedba +" The $eight bearing ould be a0 end bearing' b0 side bearing or 0 pro*imal bearing" The modern method of total onta t so +et has made $eight bearing more omfortable to patients" The ph#siologi al method of $eight transmission is through the terminal ends of bones" ,en e' artifi ial limbs $ith $eight bearing through the al aneum' lo$er end of tibia or lo$er end of femur' are more ph#siologi al" The S#me6s amputation and +nee disarti ulation are be oming in reasingl# popular' from the point of !ie$ of limb fitting" A good stump should be neither too long nor too short" It should ha!e good mus le po$er $ith full mo!ement in the pro*imal %oint and a health# non adherent s ar" It should ha!e a flesh# end $ith no bon# spurs" The are of the stump onsists of1 a0 Stump bandaging $ith repe bandage to impro!e its shape for limb fitting" b0 Stump e*er ises to impro!e its motor po$er and mo!ements in the pro*imal %oint" 0 Stump h#giene to maintain the s+in and s ar in good ondition" The amputation ma# be the end of the management of the patholog# but it is the beginning of the phase of retraining of the stump for prostheti fitting and fun tional restoration" .OMPLI.ATIONS O) AMPUTATION Treatment of .ompli ations Immediate1 a0 Infe tion b0 Se ondar# haemorrhage 0 S+in sloghing These are pre!entable b# ontrol of infe tion and proper te hni(ue in suturing" Late1 a0 Stump Neuroma b0 Phantom Limb 0 .ontra tures

Infe tion must be !igorousl# ontrolled as it ma# lead to sloughing of the edges of the flaps or e!en osteomyilitis $ith se(uestrum formation" Se!ere infe tion an lead to separation of a ring sequestrum from the tip of the se tioned bone" This also ends in pu +ered and adherent s ar $hi h is painful $hi h interferes $ith proper limb fitting" Neuroma1 This is the de!elopment of a bulbous s$elling at the ut ner!e end" It is tender and auses pain on $eight bearing" Pain ma# be relie!ed b# lo al h#dro ortisone in%e tion or in some ases b# ultrasoni therap#"

Phantom Limb1 In this ondition the patient feels that the limb is still present and he ma# feel e!en pain in some areas in the non e*istent foot or toes" It usuall# lears up $ith assuran e' analgesi s' stump e*er ises and regularit# in the use of prosthesis" AMPUTATION IN .,IL-REN The spe ial feature of amputations in hildren is the gro$th potential of the bone in the stump" In ases of belo$ +nee or abo!e elbo$ amputation in hildren' the bone in the stump ontains the growing epiphyseal plate of the upper end of tibia and the upper end of humerus respe ti!el#" In the #ears follo$ing the amputation' the gro$th of the bone ontinues" If the stump is o!ered snugl# $ith the s+in flap' the subse(uent gro$th of the bone $ill stret h the s+in in the tip of the stump and the bone ma# e!en tend to protrude" This $ill need a revision amputation to e* ise the e* ess bone" One must remember to lea!e the s+in flaps a bit flabb# so that it $ill fit snugl# $hen the bone gro$th o urs" In the lo$er limb' disarti ulation through +nee is preferable to the abo!e +nee amputation through the femur' as there $ill be gro$th of the stump proportionate $ith the gro$th of the hild" PROST,ETI. )ITTING AN- RE,A5ILITATION The responsibilit# of the surgeon does not end $ith the healing of the $ound but must in lude the restoration of lo omotion b# orre t limb fitting and reA edu ation" The limb must fit the amputee not onl# ph#si all# but also ph#siologi all#" It must be integrated emotionall# $ith the patient and be so iall# a eptable" The medi al man6s responsibilit# does not end e!en $ith the fitting of the suitable prosthesis" The ph#si ian should a ept the philosoph# that his on ern for the patient should ontinue till the amputee is !o ationall# and e onomi all# rehabilitated" ,is in!ol!ement and guidan e should ontinue $ith the !oluntar# so ial $or+ and emplo#ment agen ies to assist the handi apped amputee to get integrated as a self reliant and dignified member of the so iet#"

5ONE GRA)TING
5one grafting is the pro edure of transplanting bone from a donor area to a re ipient area" Su h a grafting of bone tissue on a prepared bed in another bone is a surgi al pro edure often used in orthopaedi pra ti e" The te hni(ue onsists of pla ing li!e bone pie es in lose onta t $ith a health# ra$ bone surfa e to stimulate gro$th of bone tissue in the ne$ area" The grafted bone a ts as a s offold around $hi h ne$ bone tissue is laid b# creeping substitution b# !as ular in!asion from the surrounding tissues" It also stimulates ne$ bone formation b# the prin iple of induction.

Indi ations The indi ations for bone grafting are as follo$s" 2" In the treatment of nonAunion of fra tures" 3" )or filling a!ities in bone" 7" )or bridging gaps in the shafts of bones aused b# trauma' infe tion or e* ision of tumour" 8" In the surgi al fusion /arthrodesis0 of %oints" T#pes of 5one grafts The bone used for grafting ma# be obtained from a donor site from a0 the same person /autogenous graft0 b0 a different person /homogenous graft or allograft0 0 a different spe ies /heterogenous *enograft0 li+e alf or pig" The best is the autogenous graft but it is diffi ult to get enough bone for use in hildren" In su h ases' the maternal homogenous graft is the best alternati!e sour e" Cadaver bone' stored in Tissue 5an+s is e*tensi!el# used not onl# to fill gaps but also to repla e diseased ends of long bone or e!en total %oints" In terms of anatomi al t#pes' the graft ma# be either Cortical bone graft in !arious shapes or Cancellous bone pie es in the form of sli!ers of hips" The an ellous bone is more osteogeni as its !as ularisation is (ui +er and bone indu tion better" The orti al bone fun tions as a fi*ation de!i e and an ellous bone promotes osteogenesis" 5one 5an+ &ith in reasing use of bone grafting pro edures for !arious ondi tions' the need for large (uantities of bone is great" This is met b# storing bone in bone ban+s $ith spe ial te hni(ues of storage in sterile and !iable ondition" 5one grafting operations The t#pe of bone grafting pro edure depends on the biologi al and me hani al situation in a parti ular ase" On lay bone graft is the most ommon t#pe $herein a orti al graft from tibia in the re tangular shape of a plate is fi*ed a ross the prepared re ipient site $ith metalli s re$s" This method is often used in the treatment of nonAunion of

fra tures" It a ts me hani all# to immobiliBe the fragments and also promotes osteogenesis" .an ellous bone hips ta+en from the ilia rest are ommonl# used as supplement to a orti al graft or a metalli plate in the treatment of nonAunion of fra tures of tibia' humerus or the forearm bones" It is also used as autogenous graft from the ilia rest or homogenous ban+ bone in filling up bone a!ities after uretting or e* ision of #sti lesions in bone" Its fun tion is mainl# osteogeni " Spinal fusion is the pro edure $hi h needs the largest (uantit# of an ellous bone graft in the operation for s oliosis" .an ellous bone hips are used to supplement ,arrington or other metalli rods" A orti o an ellous plate of bone ta+en from the ilia bone is used as a , shaped graft to stabilise lumbosa ral %un tion' supplemented b# an ellous hips" Pieces of ribs are used in anterior and anterolateral spinal fusion after uretting or tuber ulous lesion in the !ertebra in the ,ong+ong operation" The upper end of fibula is !er# useful as a bone graft for repla ing the lo$er end of radius affe ted b# giant ell tumour" 4as ularised bone graft The su ess and the rate of integration of the bone graft $ith the re ipient site is !astl# impro!ed $hen the blood suppl# is retained" This has been a hie!ed b# remo!ing the graft $ith a !as ular pedi le" This pro edure re(uires the anastamosis of the !essels b# microsurgical methods in addition to the fi*ation of the bone" This is used mostl# $hile using fibula or rib as a graft"

PLASTER O) PARIS TE.,NI>UES

GENERAL The use of loth bandages stiffened b# egg albumin and star h paste for immobilising fra tured limbs has been pra ti ed e!en in an ient Indian and Eg#ptian medi al pra ti e" E!en no$ it is used b# traditional bone setters in rural areas" The use of anh#drous g#psom as a material for splinting fra tures $as introdu ed b# a militar# surgeon in Paris' Antonius Mathesen' 2CC #ears ago and hen e the name Plaster of Paris" This is a landmar+ in the histor# of fra ture treatment" Plaster of Paris is hemih#drated al ium sulphate" On adding $ater it solidifies b# an e*othermi rea tion into h#drated al ium sulphate" GauBe bandages an be manuall# impregnated $ith plaster po$der to get plaster bandages" Read#made plaster of paris bandage rolls and slabs in !arious $idths are no$ a!ailable in the mar+et' pa +ed in air tight plasti bags and tins" The moistened plaster sets anmd hardens normall# in 7 to 9 minutes"

APPLI.ATION O) .OMMON PLASTER O) PARIS SLA5S Plaster of paris slabs are !er# useful as first Aid splints for fra tures of the limbs' as the# an be moulded to the in%ured part" The te hni(ue of their appli ation in a manner omfortable and safe to the patient should be +no$n to e!er# medi al pra titioner" Read# made plaster of paris rolls' in $idths of 29 ms' 2C ms and = ms are a!ailable in sealed $ater proof plasti pa +ages" A fe$ of ea h siBe should be a!ailable in e!er# Primar# ,ealth .entre and also $ith e!er# general pra titioner as part of the )irst Aid Dit" The ommon t#pes of plaster of paris slabs used in the limbs are the follo$ing" Upper limb 2" 5elo$ Elbo$ Plaster slab 3" Abo!e Elbo$ plaster slab 7" U Slab Lo$er limb 2" 5elo$ Dnee Plaster slab 3" Abo!e Dnee Plaster slab 7" Tube Plaster slab These plaster slabs are also used in the primary treatment of fr tures' to immobilise the fra tures after manipulati!e redu tion" The patient should be asked to report the next day. The ir ulatuion in the fingers should be he +ed and the presen e of an# edema loo+ed for" If there is an# e!iden e of the bandage being too tight' the bandage must be slit from end to end and a fresh dr# gauBe bandage applied o!er it" The slabs are later on!erted into plaster asts 7 to 9 da#s after the manipulati!e redu tion" The dela# gi!es time for the lo al edema in the limb to appear and then subside" Appli ation of complete plaster casts immediatel# after the redu tion of fra tures e!en $ith padding' is dangerous' as the fra tured limb al$a#s s$ells up after manipulation and a ast ould be ome dangerousl# tight and endanger the ir ulation to the limb" 5ELO& EL5O& PLASTER SLA5 This is used in all ases of in%uries to the $rist and the meta arpal bones' either as a first aid splint or for primar# immobilisation after the redu tion of the fra tures" Te hni(ue of Appli ation

The plaster slab e*tends from a point about 9 m belo$ the top of the ole ranon to the le!el %ust pro*imal to the +nu +les in the dorsum of the hand and the distal rease in the palmar aspe t" 2" Measure the abo!e distan e $ith a guaBe bandage strip and pla e it on the smooth table top" 3" A role of 29 ms plaster of paris bandage is unrolled on the table to a length e(ual to the measured bit of bandage and ta+en to and fro o!er it' forming < la#ers of slab in a dr# form" Its ends are folded in an on ertina fashion and +ept read#" 7" Appl# a la#er of dr# guaBe bandage around the forearm to %ust belo$ the elbo$" 8" ,old th#e folded plaster slab in the folded position and immerse it in $ater for about ; se onds b# $hi h time the air bubbles stop coming up" 9" Ta+e it out of the $ater and gentl# s(ueeBe out the e* ess $ater" ;" Spread the slab on the table top and smoothen the surfa e b# stro+ing $ith the palm till the slab is smooth and free from air bubbles" <" Appl# the slab on the dorsal aspe t of the forearm and the dorsilateral aspe t of the $rist and rub is smooth so that the lo$er end of the radius is gentl# gripped b# the slab" =" Ta+e a roll of 2C ms broad gauBe bandage' soa+ it $sell in $ater and s(ueeBe out the e* ess $ater" E" Appl# this $et bandage around the forearm' starting from the distal end to fi* the slab around the limb from end to end in a smooth fashion" On setting and dr#ing' it forms a strong splint' moulded to the shape of the forearm and hand. 2C" The forearm is held $ith the elbo$ in a EC degree fle*ed position and the $rist in the position of function of 39 degree dorsifle*ion" The fingers should be free to mo!e dull# at

the meta arpo phalangeal %oints" The splinted forearm is suspended from the ne + using a uff and ollar" A5O4E EL5O& PLASTER SLA5 This is used in the first aid splinting as $ell as in the primar# treatment of fra tures of the forearm bones" This e*tends from the middle of the upper arm to the point %ust pro*imal to the +nu +les in the dorsum of the hand" 2" A slab e(ual to the abo!e length is prepared dr# as des ribed abo!e' in < la#ers using a 29 ms plaster of paris roll" 3" The patients forearm is held in midprone position $ith the elbo$ in EC degree fle*ed position" A la#er of soft cotton roll is applied around the elbo$" A la#er of dr# gauBe bandage is applied from the hand up to the middle of the arm' fi*ing the otton roll around the elbo$ to prote t the blood !essels from pressure" 7" The slab is applied along the posterior aspe t of the arm' elbo$ and the forearm do$n to the +nu +les" Ma+e slits /about 9 m0 a ross the slab at the inner and outer aspe ts of the elbo$ %oint rease" O!erlap the ut edges and smooth out the bend $ithout @dog ears@" 8" To strengthen the slab' at the elbo$ %oint le!el' another slab of 9 la#ers is made and applied starting on the medial aspe t at the top end of the first slab rossing around the point of the elbo$ and going up$ards on the lateral aspe t to the top end" The posterior edge of the slab is slit at the elbo$ le!el' ut ends o!erlapped' and rubbed o!er smoothl# $ithout dog ear" 9" The slab is fi*ed to the limb b# appli ation of a wet gauze bandage as des ribed earlier" ;" &hen the bandage goes a ross the ubital fossa' see that the middle and not the edge of the bandage lies over the joint crease. The edge of the bandage opuld onstri t the

elbo$ dangerousl#' if it lies along the %oint rease $hen the %oint s$ells up after the appli ation of the slab" <" The splinted forearm is again suspended from the patients ne + $ith a uff and ollar" U PLASTER SLA5 This is a U shaped plaster slab used in ases of fra ture humerus" Measure the length from the root of the neck o!er the shoulder do$n to the elbo$ and a ross to the medial side and up to the a*illa" Appl# soft otton roll around the shoulder %oint and around the elbo$" Prepare a plaster slab of the abo!e measured length" Moisten' smoothen and appl# it' starting at the root of the neck' o!ering the shoulder a little posteriorl# and then laerall# do$n to the elbo$ and then a ross the point of elbo$ and going up on the medial aspe t ba + to the a*illa" A short 7C m long slab is prepared and applied at the top end of the first slab to o!er the anterior aspe t of the shoulder" The slabs are fi*ed $ith a $et gauBe bandage and a uff and ollar gi!en" A5O4E DNEE PLASTER SLA5 This t#pe of plaster slab is applied in ases of in%uries around the +nee and fra tures of the tibia and fibula" It e*tends from the middle of the thigh along the ba + of the leg and heel to the base of the toes" Te hni(ue Prepare a dr# plaster slab to the abo!e length' $ith = la#ers from a 29 m plaster of paris roll" Prepare t$o side slabs of length 2C m shorter than the posterior slab' ea h $ith ; la#ers" The patient lies on his ba +" An assistant holds the leg about 39 m abo!e the ou h $ith one palm under the +nee and the other hand holding the toes" The +nee is held in 9 degree fle*ion and the foot +ept at neutral position" .o!er the patient6s +nee $ith a la#er of soft otton rollF appl# another pad around the an+le and heel" Appl# a la#er of dr# gauBe bandage firml# from the base of the toes to the middle of the thigh" Appl# the first slab after moistening' starting o!er the sole of the foot and along the posterior aspe t of the leg and thigh and mould it to the leg b# rubbing and smoothening it" Slit the slab on either side at the heel and tu + the ut edges properl# to a!oid @dog ears@" Appl# the side slabs on the medial and lateral sides of

the limb and o!ering the heel" Mould the slabs o!er the leg b# smoothening the slabs" )i* the slab $ith wet gauBe bandage' holding the limb in the orre t position des ribed abo!e" Rest the leg on t$o sand bags' one behind the +nee and a smaller one behind the an+le" APPLI.ATION O) 5ELO& DNEE PLASTER SLA5 The belo$ +nee plaster slab is applied in ases of in%uries to the an+le and foot" It e*tends from the le!el of the tibial tuber le' posteriorl# do$n the alf' an+le' heel and sole to the base of the toes" Prepare a dr# plaster slab of eight la#ers e(ual to the abo!e length' using a 29 ms roll" Prepare t$o slabs ea h about 2C m shorter' for use in the medial and lateral aspe ts of the leg" Appl# the first slab from about 9 m belo$ the popliteal rease' along the ba + of the alf' heel and sole" Appl# the side slabs on the medial and lateral sides' as in the Abo!e Dnee plaster slab" )i* the smoothened out slabs to the leg $ith a $et gauBe bandage +eeping the foot in neugtral position" APPLI.ATION O) TU5E PLASTER SLA5 In some ases of in%uries around the +nee' another t#pe of plaster slab alled the @Tube plaster slab@ is applied" This e*tends from the upper third of the thigh to a point %ust abo!e the an+le %oint lea!ing the %oint free to mo!e" A soft otton roll is applied %ust abo!e the an+le to prote t the Tendo A hilles from the edge of the plaster slab" The slab is applied in three parts' one posterior and one on ea h side o!erlapping the posterios slabF the# are fi*ed to the limb b# a $et guaBe bandage" Conversion of the .!. or ".!. plaster slab into complete plaster casts. This is done 7A9 da#s after the appli ation of the plaster slab allo$ing time for s$elling to subside" Slit the bandage anteriorl#" As one assistant grips the dr# slab tightl# to en ir le the limb' appl# a soa+ed and s(ueeBed roll of 29 m plaster bandage around the limb starting from the toe le!el and going up$ard to the top of the slab" The ast is $ell polished and the date is mar+ed on it using a op#ing pen il"