Basics of Splinting and Casting

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Chapter 12 Basics of Splinting and Casting

Basic principles

First, Do No Harm

1. Make sure that the potential complications of applying and maintaining a cast or splint are less severe and less likely than the complications of an untreated injury.
2. A poorly made splint/cast can result in pressure sores, compression neuropathies, joint stiffness, and complex regional pain syndrome.
3. Never place a circumferential rigid dressing (cast) over an increasingly edematous limb because compartment syndrome can result.
4. Elastic bandages such as an all cotton elastic (ACE) bandage should be applied loosely so that the elasticity can accommodate any future swelling.
5. Elbows, forearms, and the lower leg and foot have the highest risk of compartment syndrome after cast application. Use caution when applying a cast in the acute setting.
6. Because plaster can expand, it is better to use plaster rather than the more rigid fiberglass cast in the acute setting.
7. Plaster and fiberglass cure with an exothermic reaction; thus inadequate padding, lack of exposure to ambient air (under a blanket), or use of water that is above room temperature can result in thermal injuries, including second-degree burns.

What to Immobilize

1. For intraarticular or periarticular fractures, the bone proximal and distal to the joint involved should be included (one above and one below).
2. For extra-articular fractures, immobilize one joint above and one joint below.
3. Immobilizing more joints than is necessary can result in permanent iatrogenic loss of joint motion.
4. Immobilization of fewer joints than is necessary can result in fracture displacement, neurovascular injury, and unnecessary pain and suffering.
5. Examples of correct immobilization:

a. Wrist fracture (distal radius):

(1) Bone above = the radius; begin the cast/splint above the elbow to prevent forearm (radial) rotation at the wrist.
(2) Bone below = the carpals; end the cast/splint just proximal to the metacarpophalangeal joints (Figures 12-1 and 12-2).

b. Tibial shaft fracture:

(1) Joint above = the knee; begin the cast/splint as high up the leg as possible to limit knee motion.
(2) Joint below = the ankle; end the cast/splint just proximal to the toes to limit ankle motion.

c. Ankle fracture (distal fibula/tibia):

(1) Bone above = the fibula + tibia; begin the cast/splint just distal to the knee joint.
(2) Bone below = the talus; end the cast/splint just proximal to the toes.

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Figure 12-1

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Figure 12-2

What Position to Immobilize

1. Unless a pressing reason exists to do otherwise, each joint should be immobilized in the optimal position to retain joint mobility after the cast/splint is removed.
2. Specific positions:

a. Shoulder: adduction and internal rotation (Figure 12-3)
b. Elbow: 90 degrees of flexion (see Figure 12-3)
c. Wrist: 30 degrees of extension (Figure 12-4)
d. Thumb: midway between maximal radial and palmar abduction (Figure 12-5)
e. Hand: intrinsic plus (metaphalangeal joints in at least 70 degrees of flexion and interphalangeal joints in extension) (Figure 12-6)
f. Hip: 10 to 30 degrees of abduction, 20 to 45 degrees of flexion, 15 degrees of external rotation
g. Knee: 15 to 30 degrees of flexion (Figure 12-7)
h. Ankle: neutral dorsiflexion (Figure 12-8)

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Figure 12-3

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Figure 12-4

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Figure 12-5

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Figure 12-6

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Figure 12-7

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Figure 12-8

Bivalving

1. If a cast is placed in the acute setting and edema is a concern, the cast can be split longitudinally along two sides (bivalving).
2. Splitting the cast material and the cast padding provides the most decompression.
3. Split the cast in a way such that divergence of the two cast “halves” does not compromise fracture reduction. For example, for distal radius fractures, split the cast directly dorsally and volarly (Figures 12-9 and 12-10).
4. For minimal edema, a single split can be performed (monovalving).
5. After the cast is split, overwrap it with either self-adhesive or elastic bandages.
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Figure 12-9

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Figure 12-10

Wedging

1. If the fracture reduction is acceptable in translation but not in angulation, the cast can be cut transversely on the acute angle of the malreduction and a wedge inserted to change the angle of the cast (Figure 12-11).
2. Because it is difficult to calculate the size of the wedge, it is best to apply a temporary wedge while radiographs are taken, followed by definitive wedge placement. Tongue depressors can be used as temporary wedges (Figure 12-12).
3. Wedges should be made out of plaster even if the cast is fiberglass (Figures 12-13 and 12-14).
4. Overwrap with the same material as the remainder of the cast (Figure 12-15).
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Figure 12-11

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Figure 12-12

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Figure 12-13

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Figure 12-14

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Figure 12-15

Cast Removal

1. Overview

a. A cast saw is an oscillating saw designed to cut hard cast material while minimizing trauma to soft material, such as cotton padding and skin.

(1) The oscillations generate significant heat and can easily burn a patient.
(2) Approximately 1% of cast removals are associated with a cast saw burn (Figure 12-16).

b. A cast saw is necessary for removal of fiberglass casts (Figure 12-17).
c. Plaster casts can be unraveled after they are soaked in water for several minutes; however, finding the leading end of the plaster strip can be difficult.
d. Do not attempt to place any cast if a cast saw is not available, because emergent removal or trimming of the cast may be necessary.
e. A cast spreader can be very helpful in separating the two halves of a cast after they have been split (Figure 12-18).
f. We recommend that a cast saw be attached to suction to limit the volume of aerosolized particulate debris on clothes and in your lungs (Figure 12-19).
g. Removal of waterproof casts is associated with a higher risk of cast saw burns because the padding is less heat resistant and thinner than is conventional cast padding.

2. Technique

a. It is important to use an “up, over, down” technique when cutting a cast.
b. The cast saw should be pushed directly down into the cast (Figure 12-20). Your index finger should rest on the cast to limit the excursion of the cast saw.
c. The saw should then be removed by coming straight back up.
d. The saw should then be moved longitudinally to the next point on the cast.
e. The saw is then reinserted using the same technique.
f. Intermittently check the temperature of the blade. The blade can be cooled with an alcohol wipe.
g. Never drag the cast saw along the cast. This technique significantly increases the risk of a cut or a burn.

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Figure 12-16

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Figure 12-17

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Figure 12-18

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Figure 12-19

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Figure 12-20

Materials

Stockinette

1. Stockinettes are available in 1- to 6-inch widths and in rolls of several yards in length.
2. Stockinettes may be used as a border to provide a more finished appearance to casts (Figure 12-21).
3. Stockinettes may be used for traction set-up (Figure 12-22).
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Figure 12-21

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Figure 12-22

Cast Padding

1. Cast padding is available in cotton, synthetic, and waterproof varieties and in sizes ranging from 1 to 6 inches (Figure 12-23).
2. We prefer the cotton variety of cast padding because it expands more evenly, is more comfortable, and is easier to work with compared with other varieties.
3. Use cast padding to provide a cuff between the casting material and the skin.
4. Avoid placing a seam of cast padding or too much padding material on the flexion side of a joint, because pressure ulcers can result (Figure 12-24).
5. Avoid wrinkles and creases in the cast padding, which can result in pressure ulcers (Figure 12-25).
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Figure 12-23

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Figure 12-24

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Figure 12-25

Plaster

1. Plaster is available in sizes ranging from 1- to 6-inch-wide rolls and strips (Figure 12-26).
2. The plaster content and quality of the rolls and strips varies by manufacturer.
3. We prefer Gypsona because it has a high plaster content, makes a nice, smooth finish on the outside, and feels silky to apply.
4. Plaster can be used for any splint or cast.
5. Plaster holds a mold better than fiberglass does and is the material of choice when a reduction is required.
6. Plaster expands more than fiberglass and is better suited to the acute setting.
7. Unlike fiberglass, plaster loses all structural integrity in water and must be kept dry.
8. A plaster splint/cast will take 24 hours to fully cure.
9. Avoid air pockets or bubbles in the plaster, which form a stress riser inside the cast and lead to structural failure.
10. Avoid direct contact between the skin and plaster, which can result in abrasions and lacerations.
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Figure 12-26

Fiberglass

1. Fiberglass is available in a variety of sizes and colors ranging from 1 to 6 inches and from hot pink to army green (Figure 12-27).
2. Fiberglass takes just a few minutes to reach near full structural integrity and is more resistant to deformation than is plaster. Because of these qualities, molding with fiberglass is much more difficult than molding with plaster.
3. Water does not compromise a fiberglass cast, and waterproof cast padding can be used if a patient intends to go in the water or if it is suspected he or she will do so.
4. Fiberglass can be used to hold a nondisplaced fracture in position.
5. Use cut-to-length fiberglass splints with caution:

a. Pad the edges (which can be as sharp as cut glass).
b. Use the correct width.
c. Place the padded side toward the skin.

6. Be sure to wring out any excess moisture from the fiberglass after activating it in water to prevent maceration of the cast padding.
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