DOI: 10.1097/01.prs.0000233620.73320.23
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PMID: 17255725
Issn Print: 0032-1052
Publication Date: 2007/01/01
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Excerpt
Traditional teaching in pediatric hand surgery calls for a hard, above-elbow cast in the early postoperative period. This longstanding dogma understandably arose from the exasperating proclivity of children to wriggle out of below-elbow casts, often with an ease and alacrity that would make Houdini envious. Many a brash young hand surgeon has foolishly attempted a seemingly more reasonable below-elbow dressing, only to see the child extricate himself even before leaving the recovery room. Nevertheless, the allure of a below-elbow dressing is undeniable even to the hardened veteran of pediatric hand surgery, particularly in cases of digital soft-tissue injuries for which an above-elbow cast seems exorbitant to parent and patient alike. Besides being heavy and encumbering, the above-elbow cast is difficult to apply and introduces an additional risk of iatrogenic pressure sores about the elbow and upper arm, further compelling the surgeon to seek an alternative dressing.
In our practice, an extremely useful and effective alternative has been a below-elbow Coban bandage. The principle advantage of Coban (3M, St. Paul, Minn.) is its self-adherence, which prevents unraveling and greatly limits the child’s ability to escape from the dressing. We have applied Coban bandages with great success in a variety of situations, including fingertip or nailbed injuries, distal phalanx fractures, and skin grafting. In every case we have been impressed with the durability and tolerability of the bandage, and in no case has a patient removed it prematurely.
Depending on the circumstance, we typically apply a nonadherent dressing to the wound, followed by a layer of gauze between the fingers and around the distal extremity, followed by several layers of Coban. The final wrap is begun by unrolling the Coban along the axis of the fingers and folding it over the fingertips, alternating between the volar and dorsal surfaces. It is then wrapped helically around the hand and forearm, as with a typical elastic bandage. The tail end of the bandage should be applied carefully, preferably over the relatively inaccessible ulnar surface of the forearm, avoiding folded or elevated corners that may later be pulled loose by the patient. The dressing can be fashioned as a club that includes all of the digits, or if appropriate as a mitten that excludes the thumb, a source of pacification for many patients (Figs. 1 and 2).
It must be remembered that the elasticity of the Coban bandage is abrogated by its cohesiveness, so that when applied, it ceases to function as an elastic bandage. Care should therefore be taken with each circumferential wrap to unroll several inches of Coban before laying it down without tension over the extremity. When wrapped in this way, we have seen no constrictive complications.
The Coban bandage holds many advantages over the hard, above-elbow cast. It is easier and quicker to apply, and it liberates the elbow from immobilization and risk of pressure sores. It is much lighter and more comfortable, such that even the most cantankerous toddler seems to adapt to and even to ignore the dressing after a short time. It is resistant to moisture and permeable to air, and after applications as long as 2 weeks, we have seen no skin maceration (Fig. 3). Although it is softer than a cast, several layers of Coban offer essentially insurmountable resistance to motion, and with the ability to apply it in a more form-fitting fashion, the Coban bandage is actually a more effective means of immobilization than a hard cast. Its softness also provides protection from injury should the child inadvertently strike himself or others.
