Splinting and casting
Introduction:
The initial approach to casting and splinting requires a thorough assessment of the
injured extremity for proper diagnosis.
Examine the skin, neurovascular status (before and after: a. reduction, b. casting or
splinting), soft tissues, and bony structures to accurately assess and diagnose the
injury.
Indication for immobilization
Fractures
Sprains
Severe soft tissue injuries
Reduced joint dislocations
Inflammatory conditions: tendinopathy, tenosynovitis.
Deep laceration repairs across joints
Tendon laceration
Materials and Equipment
Stockinet (2-3 inches for upper limb, 4 inches for lower limb)
Sheets, under pads (to minimize soiling of the patient's clothing)
Plaster or fiberglass casting material
Padding (soft rolls)
Elastic bandage (for splints)
Casting gloves (necessary for fiberglass)
Basin of water at room temperature (dipping water)
Bandage scissors
Adhesive tape
Control of sitting time
The normal sitting time is 4-5min.
Factors that speed sitting time Factors that slow sitting time
Warm water Cold water
Soft water Hard water
Fiber glass cast use Plaster of Paris (POP)
Accelerator use: potassium sulfate retarder use: sodium borate
Reuse of dipping water
The most important variable affecting the setting time is water temperature. The
faster the material sets, the greater the heat produced, and the greater the risk of
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significant skin burns. A good rule is that heat is inversely proportional to the
setting time and directly proportional to the number of layers used.
Gypsum is the precursor of P.O.P, known as calcium sulphate dihydrate.
Gypsum + heat = P.O.P + water
General Application Procedures
The physician should carefully inspect the involved extremity and document skin
lesions, soft-tissue injuries, and neurovascular status before splint or cast
application. Following immobilization, neurovascular status should be rechecked
and documented.
Pay attention to the patient comfort status and pain level; never re-align a fracture
without adequate analgesia.
The patient's clothing should also be covered with sheets to protect it and the
surrounding area from being soiled by water and plaster or fiberglass.
Types and techniques
A. Complete cast:
- Measure the length
- The physician hold the limb reduced and the assistant apply stockinet
- Stockinet; 10 cm longer than the required length, therefore can be folded
- Soft roll application; in the same position the limb will be immobilized,
avoid folds at joint line, apply extra padding at bony prominence (each layer with
50% overlap)
- Assistant immerses P.O.P in warm water until all air bubble within the
bandage disappears
- Squeeze the bandage to expel excess water
- P.O.P applied around the limb with gentle firmness, each circle should
overlap about half the width
- The plaster should be smoothed and molded
- Limb should be elevated and iced in the first 48hrs to decrease the
swelling
General roles for cast fixation:
- Immobilize the joint above and below the fracture
- Try not to immobilize any joint unnecessarily
- Immobilize the joint in functional position whenever possible; e.g. knee
10-15 degree flexion, elbow 90 degree flexion, ankle and wrist are
neutral
- At the wrist stop just proximal to the distal palmer crease, to keep
metacarpophalangeal joint free
- Proximally: A. Below elbow: two finger width distal to the elbow crease
B. Above elbow: just below deltoid insertion
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- For the foot; distally keep all the toes exposed
- Proximally: A. Below knee: Just below The tibial tuberosity
B. Above knee: upper third of the
Figure: Note handling the soft rolls and POP cast.
Figure: 50% overlap for the soft rolls when applied.
Figure: Distally the distal palmer crease should be seen, for distal lower limbs all
the toes are exposed.
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Figure: for above knee at upper third of thigh (note folding of the stockinet to
make smooth upper end), for below knee the proximal end just below tibial
tubercle, for below elbow two fingers width below elbow crease and above elbow
just below deltoid insertion.
B. Plaster slab:
- Measure the length
- The physician hold the limb reduced and the assistant apply stockinette
- Stockinette; 10 cm longer than the required length, therefore can be folded
- Soft roll application; in the same position the limb will be immobilized,
avoid folds at joint line, apply extra padding at bony prominence
- A longitudinal piece of plaster prepared to the required length, folded in
10 layers
- Assistant immerses P.O.P in warm water until all air bubble within the
bandage disappears
- Squeeze the bandage to expel excess water
- Apply dorsally and hold by gauze bandage
- Limb should be elevated and iced in the first 48hrs to decrease the
swelling
N.B: Fiberglass cast is a polyurethane resin.
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Advantages of P.O.P
- Cheap and easily available
- Versatile
- Fairly strong
- More effective immobilization compare to slab
Disadvantages of P.O.P
- More time and skills needed to apply
- More complication compared to slab
- Stiffness of immobilized joints
- Pressure problems
- Not water proof
- Heavy compared to fiberglass cast
Advantages of slab
- Faster and easier to apply
- Because a splint is non-circumferential, it allows for the natural swelling
that occurs during the initial inflammatory phase of the injury
- A splint may be removed more easily than a cast, allowing for regular
inspection of the injury site
Disadvantages of slab
- Lack of patient compliance
- Excessive motion at the injury site
Complication of cast application
- Compartment syndrome
- Ischemia
- Heat injury
- Pressure sores and skin breakdown
- Infection
- Dermatitis
- Joint stiffness
- Neurologic injury
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Cast instructions should be provided to the patient
- Keep limb elevated esp. first 48hrs
- Move fingers/toes
- Exercise all joints not included in the cast
- If fingers/toes become swollen, painful or stiff raise the limb, apply ice
and move the fingers/toes
- If no improvement in half hr return to the hospital immediately
- If the cast becomes loose or cracked report to hospital
Indication for splitting or removal of cast
- Swelling of toes/fingers without ischemia split the cast
- Swelling of toes/fingers with sign of ischemia/compartment syndrome
remove the cast and all compressive dressing down to skin
Cast removal
- A cast saw is a specialized saw made just for taking off casts. It has a
flat and rounded metal blade that has teeth and vibrates back and forth
at a high rate of speed.
- The cast saw is made to vibrate and cut through the cast but not to cut
the skin underneath.
- After several cuts are made in the cast (usually along either side, in and
out technique), it is then spread and opened with a special tool to lift
the cast off.
- The underlying layers of cast padding and stockinet are then cut off
with scissors.
Figure: Handling of the saw, in and out controlled cuts.
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References
1. Principles of Casting and Splinting
ANNE S. BOYD, MD, University of Pittsburgh School of Medicine, Pittsburgh,
Pennsylvania
HOLLY J. BENJAMIN, MD, University of Chicago, Chicago, Illinois
CHAD ASPLUND, MAJ, MC, USA, Eisenhower Army Medical Center, Fort
Gordon, Georgia
Am Fam Physician. 2009 Jan 1;79(1):16-22.
2. Fractures and dislocation
Badr and shaheen
3.Fractures in adults
Rockwood and green, Sixth edition
