22 - Casts and Wraps Flashcards
Conditions that benefit from immobilization
From MOST to LEAST
- Fractures
- Sprains
- Severe soft tissue injuries
- Reduced joint dislocations
- Inflammatory conditions: arthritis, tendinopathy, tenosynovitis
- Deep laceration repairs across joints
- Tendon lacerations
Types of immobilization
- Casts
- Splints
- Jones compression dressing
- Unna boot
- Removable cast walker
Standard materials and equipment for splint and cast application
- Adhesive tape (to prevent slippage of elastic wrap used with splints) - Now a lot of them come with Velcro, so this isn’t needed
- Bandage scissors
- Basin of water at room temperature (dipping water)
- Casting gloves (necessary for fiberglass – this will NOT come off your skin)
- Elastic bandage (for splints)
- Padding
- Plaster or fiberglass casting materials
- Sheets, underpads (to minimize soiling of the patients clothing)
- Stockinette
Casts vs. splints
Casts
o Circumferential
o Allows for greater stabilization
o Does not allow for edema as much
Splints o Posterior with possible stirrup o Not as stable o Allows for edema o Good in acute trauma
Plaster vs. fiberglass
Plaster
- Slower setting
- Excellent moldability
- Heavy
- Inexpensive
- Gets hot when setting (exothermic reaction due to gypsum – can cause burns)
Fiberglass
- Quick setting (need to work quickly)
- Good moldability (not as good as plaster)
- Light weight
- More expensive
- Has less exothermic reaction than plaster
Factors that affect setting time for casts and splints
Factors that speed setting time:
o High temperature of dipping water
o Use fiberglass
o Reuse of dipping water (residual fiberglass or plaster in water)
Factors that slow setting time:
o Cooler temperature of dipping water
o Use plaster
NOTE: these are listed in order from most clinically relevant to least clinically relevant
Steps for splint application
NOT something we will do in lab, but we do it in clinic
- Stockinette to knee then cast padding from toes to knee (pad bony prominences***)
o Usually 1 roll for foot, 1 roll for ankle - Dip fiberglass or plaster in water
- Apply posteriorly and/or medially and laterally (“Stirrups” will provide stability)
- Fold down stockinette over splint material ends
- Apply one thin layer of cast padding (not always done)
- Apply 4” ace to foot (smaller) and 6” ace to leg (larger) - Sometimes can do 4” on a small leg – just pick the best option
- Images are a posterior splint - They will NOT be walking on it, it will go from metatarsal heads to upper calf
Steps for fiberglass cast
- Stockinette from past toes to knee
- Cast padding from toes to knees (1 roll foot and 1 roll leg) - ***Make sure to pad boney prominences well – this is VERY important here
- Apply 3” fiberglass roll to foot then apply 4” fiberglass roll to leg (extra on heel and met heads for extra strength, avoid common peroneal n. around knee (foot drop))
- Fold down stockinette
- Apply 3” fiberglass roll from toes to knee (usually colored roll)
Weightbearing cast
Same as nonweightbearing except
o MUST be at 90◦
o Accordion layer about half 3” fiberglass roll the length of the foot and apply it plantarly (This will prevent the fiberglass from cracking)
o Use remainder of roll to secure and add extra strength/prevent cracking
Guidelines for proper cast and splint application
- Use appropriate amount and type of padding
- Properly pad bony prominences and high-pressure areas
- Properly position the extremity before, during and after application of materials
- Avoid tension and wrinkles on padding, plaster and fiberglass (can cause skin breakdown)
- Avoid excessive molding and indentations
NOTE: listed in chronological order
Cast removal
- Use oscillating saw designed to cut hard cast material not soft material (can’t lacerate skin with saw, can cause burns)
- Score medial and lateral aspects of cast (Guideline – medial and BEHIND malleolus then lateral and BEHIND malleolus)
- Use quick up and down motions with the saw is the best way – going slow makes it hot
- Use enough pressure to just pop through
STUDY - technique for controlling temperature fiberglass and plaster cast removal
- Poor technique was defined as keeping saw uniformly in cast while removing
- Good technique was defined as taking saw in and out of the cast to allow blade to cool
For fiberglass casts…
- The temperature of the cast was much higher when poor technique was used
- The temperature of the skin was much higher when poor technique was used and only 2 layers of cast padding was present
- There was no difference in temperature of the blade or the skin when 4 layers of cast padding were present between good and poor technique
For plaster casts…
- The temperature of the blade was much higher when poor technique was used
- The temperature of the cast was slightly higher when poor technique was used
- The temperature of the skin when 2 and 4 layers of cast padding were present was slightly higher when poor technique was used
Summary
- Technique DOES matter
- Make sure you are using good technique for patient safety, avoid burns
Complications of cast removal
- Cast saw burns can be seen in children treated with clubfoot casts (these patients are particularly at risk)
- Hypertrophic keloid formation 5 months after injury example
Complications of cast or splint immobilization
- Compartment syndrome
- Ischemia
- Heat injury
- Pressure sores and skin breakdown
- Infection
- Dermatitis (sweating, showering, sticking pencil down it, etc.)
- Joint stiffness
- Neurologic injury
Risk factors for cast complications
- Local anesthesia
- Neuropathy
- Difficulties with communication
- Chronic edema
- Improperly applied cast
- Dipping water >50 ◦C (Mainly with plaster)
