Splinting and Casting

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Limitations

• Casts hold better than correct
• Risk of pressure points
  • Pad adequately at pressure points
  • Mold cast to contours
  • Beware of plastic or metal splints
  • Don't wrap too tightly
  • Avoid motion between cast and limb

Ensuring Effectiveness

• Position
  • Counteract deforming muscle pull
  • Some fractures are unstable in certain joint positions
  • If limb is placed in abnormal position for stabilization, place in more normal position as soon as enough healing has occurred
• Extent
  • Include joint above and below fracture
• Contact
  • Padding
  • Molding
    • To prevent pressure points
    • To improve stability
    • Watch for circumferential constriction
  • Split casts placed on acute fractures to allow for swelling
  • Padding may need splitting too
  • Replace long term casts if decrease in limb swelling and increase in atrophy have made cast loose

PLASTER OF PARIS

• Discovered by Flemish Army Surgeon in early 1800's
• Hemihydrate of calcium sulfate + H2O ----> Gypsum + Heat
• Different manufacturers, different consistencies, additives, properties
  • drying time
    • Slower drying time:
    • If you're slow applying it
    • Choose faster drying time
    • struggling children
    • when trying to hold a reduction
    • Cold water---> slows drying
    • Add salt to water ---> faster drying
  • strength
  • water resistance
• Strength based on:
  • additives
  • thickness (layers)
  • cylindrical shape
  • position- angulation decreases strength
  • added splints for reinforcements
  • molding (increases strength)

PADDING

• Sheet wadding- cotton
  • good padding
  • may bunch or form ridges
  • avoid circumferential padding with no break in continuity
• Apply extra padding judiciously to bony prominences
  • may cause more pressure
  • may decrease stability
• Molding of cast decreases risk of pressure points
• Stockinette-
  • smoother skin covering
  • not always beneficial
  • may cause pressure points
  • requires additional handling of extremity to apply
• Pressure Points
  • Beware of indentations from finger tips ---> pressure points
  • Windowing over pressure point
  • apply soft padding over window
  • Consider placing window:
  • over wound/sutures
  • over pressure points
  • Reapply cast if needed
  • "Orange Peeling"

APPLYING THE PLASTER

• Use 6-inch roll
• Place roll on end, in hot water, cover roll;
• Gently squeeze, do not "wring out"
• Roll in transverse manner
• Pull out slack, and fold over a tuck, when contour of limb changes
• Roll with one hand, smooth and tuck with other
• Overlap preceding layer by @ 1/2 width
• Massage layers continuously to work plaster through
• Do not twist plaster
• Prevent telescoping of center of roll:<--- Pinch ends.
• Reinforcing:
  • straight plaster splints 3 or 6 inch width
  • incorporate into cast while applying circular bandage
• Apply long, trim to length
• Split if swelling is anticipated
  • remove 1-2 cm strip
    • allows visualization of padding (and cutting it if needed)

CAST REMOVAL

• Cast Saw
  • Roll saw edge to avoid heat buildup
  • Bivalve
  • Remove top half carefully and cut attached padding
  • May keep limb in posterior half for transport to X-Ray

CAST CHANGES

• Indications
  • Reduction in swelling
  • Limb atrophy
  • Growth of limb in child
  • Softening/damage
  • Skin damage, infection
• Beware of loss of reduction if fracture is recent
• Maintain position- watch for effects of gravity on fracture during cast changes.

REFERENCES

Lewis, RC Jr. Handbook of Traction, Casting, and Splinting Techniques JB Lippincott Company, Philadelphia, 1977