Commonly Used Bandages and Slings

The materials necessary to apply a Robert Jones bandage include one to three 1 -lb rolls of absorbent cotton, 1- or 2-inch white adhesive tape, several rolls of 3- or 4-inch stretch gauze, one to three rolls of 3- or 4-inch elastic tape or self-adherent stretch tape, and a nonadherent dressing when indicated.

Application is begun by placing adhesive tape stirrups medially and laterally from the carpal or tarsal area distally (Figure 63-1A). Dog-earing each end or placing a tongue depressor between the tape ends aids in separating the stirrups later. Placement of a nonadherent dressing on any open wound or surgical incision is done at this time.

The next portion of the bandage is the application of the cotton. One begins distally and wraps proxi-mally, high into the axillary or inguinal regions (Figure 63-1B). The ends of digits 3 and 4 should be left exposed, and the cotton should be wrapped with enough tension to make the bandage tight, but not tense enough to cause the cotton to tear. The final bandage should convert an irregularly shaped leg into a uniform-diameter or stovepipe configuration, thereby allowing the bandage to apply even pressure over the entire length of the leg (Figure 63-1C).

After application of the cotton, even pressure is accomplished by wrapping from distal to proximal with 3- or 4-inch stretch gauze (Figure 63-1D). Each wrap should overlap the previous by about 50% its width, avoiding any formation of ridges and valleys, indications of uneven pressure. When wrapping the stretch gauze, one should apply enough tension to compress or reduce the size of the bandage adequately. In most cases, the final diameter of the bandage after the stretch gauze is applied is 40 to 50% of the original diameter.
 

To complete the bandage, the tape stirrups are separated and are placed along the appropriate medial and lateral sides. Using either elastic tape or self-adherent stretch tape, the final layer is started, again distally, wrapping proximally and continuing to overlap each layer by 50% while taking care to maintain even compression. When this layer is completed, only the distal ends of digits 3 and 4 should be exposed (Figure 63-1E). If the toes are not visible, adequate amounts of the surrounding cotton should be removed to allow exposure of the digits.

The goal of the Robert Jones bandage is to provide immobilization while maintaining even compression over the length of the limb. Compression can be evaluated by tapping over the length of the bandage; a properly applied bandage sounds like a ripe watermelon when it is thumped. To obtain even compression may require several applications of the stretch gauze, beginning each wrap distally and continuing proximally to either the axillary or inguinal region. In smaller dogs and cats, cotton cast padding may be substituted for the roll cotton, thereby achieving a more uniform fit to the leg. A more uniform fit may also be accomplished by removing the paper insert in the cotton roll, tearing the roll in half, and wrapping with 6-inch widths rather than 12-inch widths of cotton strips. All layers of the bandage are wrapped in a lateral-to-medial rotation to allow for a neutral to slightly internally rotated position of the limb.

Postbandaging care should include keeping the bandage clean and dry and observing the exposed digits for swelling or coolness to the touch. If problems are noted, the bandage may have been improperly applied and should be removed and the leg reevaluated. If no signs of problems are evident, the Robert Jones bandage may be left in place for up to 3 weeks.
 

The Ehmer or figure of eight sling is a non weight bearing sling for the pelvic limb. A properly applied Ehmer sling maintains the leg in a flexed position with the coxofemoral joint abducted and inwardly rotated.

Indications

The Ehmer sling is used primarily to maintain the coxofemoral joint in a stable position following closed reduction of cranio-dorsal coxofemoral luxation. Maintenance of the coxofemoral joint in an inwardly rotated and abducted position provides for maximal coverage of the head of the femur by the acetabulum while periarticular fibrosis stabilizes the coxofemoral joint. Use of an Ehmer sling may also be beneficial in maintaining stability of the hip joint in the immediate post operative period following certain surgical procedures such as repair of fractures of the femoral head and neck, acetabular fractures, and to provide stability following open reduction of coxofemoral joint luxations.

Application Technique

The only material necessary to apply an Ehmer sling is a roll of porous, adhesive tape. I prefer to use 2” porous tape (Curity^®, Kendal Healthcare Products Company, Mansfield, MA 02048) rather than elastic adhesive tape (Elastikon, Johnson and Johnson, Somerville, NJ 08876), as the elastic type tape is more prone to create a constriction if not applied loosely. Regardless of the type of tape material used, it is advisable to first unroll, or strip off, a length of tape then re-wrap it loosely so that when the tape is applied, there is less of a tendency to tape too tightly around the foot or thigh.

To begin placement of an Ehmer sling, the tape is first anchored to the metatarsal region of the foot by wrapping the tape loosely around the metatarsals. The tape is begun on the dorsal metatarsus, proceeds to the lateral and then plantar aspect of the metatarsus. The limb is then flexed, taking care not to hyperflex the hock joint, and the tape is continued up the medial aspect of the tibia, medial to the stifle joint and medially over the thigh muscles (Figure 63-2). The tape should not be passed up the medial aspect of the tibia, caudal to the stifle joint and over the lateral side of the thigh muscles as this predisposes the tape to slipping off the cranial thigh muscles (Figure 63-3). After the tape is passed up the medial aspect of the thigh muscles, it is brought over the cranial thigh muscles to the lateral side of the thigh and continues distally caudal to the stifle joint, medial to the distal tibia and hock, and passes under the plantar aspect of the metatarsals from medial to lateral (Figures 63-4 and 63-5).
 

Two or three wraps of tape are continued in a manner similar to that previously described. Properly applied, the toes should point slightly inward, the hock joint should be rotated outward and the stifle and coxofemoral joint should be rotated internally. To provide maximal coverage of the femoral head by the acetabulum, abduction of the limb is provided by passing a length of tape from the plantar metatarsal region, over the lateral aspect of the flexed limb and around the abdomen where it is attached to a pre placed bellyband (Figure 63-6). Care should be taken to stay cranial to the prepuce with the bellyband in male dogs. If using an Ehmer sling to stabilize a ventral coxofemoral luxation, the limb is not abducted as this will predispose to re-luxation.
 

Aftercare and Potential Complications

A properly applied Ehmer sling is well tolerated by most dogs. The sling should be left in place for 2 to 3 weeks following closed reduction of coxofemoral luxations and following open reduction of coxofemoral luxations using the trans acetabular pinning technique.¹ Immobilization of joints beyond 4 weeks should be avoided as potentially irreversible changes such as capsular and pericapsular contracture, proliferation of intracapsular connective tissue, and major cartilage alterations may occur.² Owners should be instructed to check the sling daily for slippage and to observe the toes daily for potential swelling. Should swelling of the toes be observed, the owner should be instructed to return the animal immediately to have the sling removed and re applied correctly.

The primary complication from a properly applied Ehmer sling is skin irritation from the tape. This is most noticeable over the cranial aspect of the thigh musculature, and will resolve with conservative management once the sling is removed. Occasionally, a short course of antibiotic therapy is used. In male dogs, the bellyband may produce irritation cranial to the prepuce or cause preputial swelling if it slips caudally; it should be monitored and adjusted as needed.

References

1. Tomlinson JL. Reduction of coxofemoral luxations. In Bojrab MJ (ed), Current Techniques in Small Animal Surgery (4th ed). Philadelphia 1998; Lea & Febiger, pp 1180-1182.
2. Herron AJ. Fracture disease. In Bojrab MJ (ed), Pathophysiology in Small Animal Surgery (2nd ed). Philadelphia 1981; Lea & Febiger, pp 697-699.
    

Introduction

Compromised stifle joint function is a frustrating complication of surgery on fractures of the femur. This process develops most readily when the limb is carried or is splinted in extension. This may be a result of tension created in the quadriceps muscle group after fracture reduction or splinting. The resulting abnormal gait and decreased weight-bearing of the limb can induce disuse osteoporosis, muscle atrophy, and articular changes. Periarticular connective tissue contracture and abnormal joint motion lead to irreversible degenerative joint disease of the stifle. In addition to these changes, growth disturbances such as hip subluxation and bone hypoplasia may develop when quadriceps contracture affects immature animals. A review of femoral fracture cases supports the type of circumstance considered to be high risk for development of stifle joint stiffness.¹ These“ at risk”fractures are those that involve the immature patient and/or those with considerable bone comminution and soft tissue damage. When these situations exist and involve the distal third of the femur the risk is quite high. In addition, risk is high when multiple trauma results in involvement of other bones and joints in the same limb and/or other limb(s) in conjunction with the femoral fracture.

Various treatment modalities have been used for correction of this problem. For the most part these treatments have been active and passive physical therapy modalities and surgical manipulations. The goals of these treatments are restoration of stifle joint and limb function, but significant clinical improvement is unpredictable and costly. Especially common for these types of cases is to attempt manual passive flexion and extension of the stifle after the development of stiffness. It has been suggested in a research study in rabbits that passive therapy only prevents stiffness if it is conducted continuously for more than 16 hours a day for three weeks. Further, it was noted that to do passive therapy for less time per day would actually produce more stiffness.²

Because of the great difficulty in treating stifle stiffness once it has occurred it is important to use techniques that contribute to prevention of stiffness. Undoubtedly, providing a stable osteosynthesis will encourage early weight-bearing and contribute to prevention of joint stiffness. However, even situations with stable fracture repair can develop joint stiffness.¹ This has been of clinical importance in humans; as a result, the Association for the Study of the Problems of Internal Fixation has recommended that all fractures of the middle and distal femur be held for the first five postoperative days with the knee positioned in 90 degrees of flexion.³ A similar technique (90-90 flexion splint) has been evaluated in the dog and cat and appears to be a strong deterrent to the development of stifle stiffness with these types of cases.¹

The 90-90 flexion splint needs to be applied in the immediate postoperative period to be effective and is not generally helpful if applied after development of stifle joint stiffness.¹ The amount of time the splint should be used for prophylaxis is empirical. However, to avoid the risk of developing stiffness in flexion the joint should not be held by the prophylactic splint for more than seven days. The splint is usually used for three to five days. Gravity may play an important role in allowing the good extension noted after only a day or two following removal of the flexion splint.

Technique

(Figure 63-7)
The only material necessary for application of the 90-90 flexion splint is a roll of elastic tape.ⁱ One can use a small amount of gauze under the tape to cover an incision. Using too much padding of any type will tend to lead to slippage of the splint. Apply the 90-90 flexion splint in a similar fashion to an Ehmer sling. However, unlike the Ehmer sling place both stifle and hock joints in approximately 90° of flexion, not maximal flexion. While holding the hock and stifle 90° begin by applying adhesive tape loosely around the metatarsal area. Direct the tape up the medial aspect of the tibia. Pass the tape to the medial side of the thigh then around the cranial femur onto the lateral thigh and return to the starting point. Repeat this two or three times attempting to place the tape high in the inguinal region at the top to prevent it from slipping off the cranial aspect of the thigh.

Last, place tape strips perpendicular to the already applied tape to encircle the tibia from cranial to caudal to squeeze the tape and further prevent it from slipping. There is no effort, however, to maintain hip abduction as is recommended for the Ehmer sling. A properly applied 90-90 splint is well tolerated by most dogs and cats. Monitor the splint for areas of irritation and especially the toes for swelling. If the toes or distal limb starts to swell, the splint must be removed immediately. Irritation of the skin in the groin region may occur. This is usually minor and is managed conservatively following splint removal.
 

ⁱ Elastikon^TM Johnson & Johnson, New Brunswick, NJ 08933

Suggested Readings

Aron DN, Crowe DT: The 90-90 flexion split for prevention of stifle joint stiffness with femoral fracture repairs. Am Anim Hosp Assoc 23:447, 1987.

References

1. Aron DN, Crowe DT: The 90-90 flexion split for prevention of stifle joint stiffness with femoral fracture repairs. Am Anim Hosp Assoc 23:447, 1987.
2. Gebhard JS, Kabo JM, Meals RA: Passive motion: the dose effects on joint stiffness, muscle mass, bone density, and regional swelling. A study in an experimental model following intra-articular injury. J Bone Joint Surg Am 75:1636, 1993.
3. Muller ME, Allgower M, Schneider R, Willenegger H: Manual of internal fixation: Techniques recommended by the A-O-groups. 2nd ed. Berlin: Springer-Verlag, 1979, 246.