Lower Extremity Splints and Casts

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Chapter 14 Lower Extremity Splints and Casts

Hip spica cast

Overview

1. The hip spica cast is one of the most difficult casts to apply.

2. The hip spica cast generally is composed of an abdominal portion attached to long leg casts, which is a so-called “double spica cast.” When the unaffected extremity is placed into a thigh-only cast, the cast is termed a “1½ spica cast.” A “single leg” hip spica cast is composed of an abdominal portion attached to a single long leg cast of the affected leg. All three types of spica casts have been shown to be successful in treating diaphyseal femoral fractures in children younger than 6 years.

3. The following points regarding the application of a hip spica cast are controversial:

a. The type of spica cast that should be used (double, 1½, or single leg)

b. Whether the foot should be included in the cast

c. When to apply traction while casting

d. Whether to apply the abdominal or the leg portion of the cast first

e. Positioning of the extremity

Precautions

1. The following complications of hip spica casting may occur:

a. Compartment syndrome has been reported in the 1½ spica cast with the hip and knee flexed to 90 degrees.

b. Femoral and peroneal nerve palsy can occur, respectively, from excessive hip flexion and valgus molding over the fibular head.

c. Skin breakdown and decubitus ulcers can occur.

d. Superior mesenteric artery syndrome can occur from excessive thoracolumbar lordosis in the abdominal portion of the cast.

2. Close monitoring of the patient for complications is necessary during the first 2 weeks after application of the cast.

3. Some authors argue that initial femoral shortening greater than 2 cm is a contraindication for treatment with a spica cast.

4. Families caring for children with spica casts must contend with numerous psychosocial issues, such as transportation and bathing.

Pearls

1. We prefer a relaxed leg position with the knee at 60 degrees of flexion and the hip in 45 degrees of flexion rather than the traditional 90-90 position. An assistant should help the patient maintain this position throughout the application of the cast to avoid any bunching or creasing of the casting material.

2. Application of the cast can be performed in the emergency department with use of conscious sedation or in the operating room (OR) with use of general anesthesia.

3. Although they may not always be available, use of waterproof Gore-Tex pantaloons and a cast liner significantly improves the ability of the family to care for a child with a spica cast.

4. A broomstick, a twisted bar of fiberglass casting material, or some other connecting bar can be used to confer additional stability and strength to the spica cast.

5. Placing the spica table into a 10 degrees of reverse Trendelenburg position, either by tilting the operating table or by placing a block of wood under the spica table, allows the child’s perineum to fit snugly against the perineal post of the spica table.

Basic Technique: 1½ Spica Cast

1. Patient positioning:

a. The patient should be placed on the hip spica table (Figure 14-3).

(1) The buttocks and perineum should be placed on the adjustable post.

(2) The thoracic spine should sit on the table extension.

(3) The shoulders and thorax should be on the platform portion of the table.

b. The knee should be held at 60 degrees of flexion and the hip in 45 degrees of flexion. The hip should be abducted 20 to 30 degrees and the extremity should be externally rotated 15 degrees.

2. Where to start:

a. A long leg cast is applied to the affected extremity starting with the foot.

b. The foot should be included and placed in a neutral position.

3. Where to finish:

a. The spica cast should extend proximally to the level of the rib cage.

4. Where to mold:

a. A valgus mold should be placed at the fracture site.

Figure 14-3

Detailed Technique

1. Prepare a stockinette:

a. Cut two pieces from a 2-inch stockinette:

(1) One piece is for the long-leg portion of the spica cast, measuring from the inguinal crease to 2 inches beyond the foot.

(2) One piece is for the contralateral thigh.

b. Cut one piece from the 4-inch stockinette. This piece will be used for the abdominal portion of the spica cast and should measure from the nipples to the mid thigh.

2. Place the patient on the spica table. Have an assistant consistently hold the patient in the desired position.

3. Position the stockinette (Figure 14-4):

a. Place the abdominal stockinette on the patient with the stockinette extending from the nipples to the mid thigh. Posteriorly, the stockinette should be placed over the spica table extension (i.e., the table should be in contact with the skin of the thoracic spine).

b. Place the long-leg stockinette over the affected extremity and the unaffected-leg stockinette over the thigh of the contralateral leg.

4. Place two to four blue OR towels on the abdomen under the stockinette to allow for abdominal excursion after application of the cast.

5. Begin preparing the long leg cast on the affected extremity.

7. Create a cast padding cuff (see Chapter 12) for the metatarsal heads. This cuff should form a “V” at the lateral aspect of the foot to allow for the cascade of the digits (Figure 14-7).

8. Wrap the abdomen in cast padding (Figure 14-8). Ensure that the anterior superior iliac spine, posterior superior iliac spine, and sacrum are very well padded.

9. Wrap the contralateral thigh in cast padding. Start immediately proximal to the popliteal fossa and continue proximally to the gluteal fold.

10. Create a cuff of cast padding (Figure 14-9) and place it over the most distal part of the rib cage.

11. Create a cuff of cast padding.

a. Place the cuff over the distal portion of the thigh.

b. The knee should be able to bend to 90 degrees without impediment from the cast.

12. Finish the cast edges (Figure 14-10). All exposed areas should have the stockinette pulled up and folded over the cast padding.

13. Pay particular attention to the perineal portion of the cast.

14. Apply cast material as for a long leg cast.

a. Start distally at the metatarsal heads and extend proximally to the mid thigh.

b. Ensure that a significant amount of stockinette and cast padding remains to the level of the gluteal fold (Figure 14-11).

c. Be vigilant about the position of the foot.

15. Begin application of the abdominal portion of the spica cast and the contralateral thigh portion of the cast for the unaffected leg.

a. Begin proximally at the level of the abdominal cuff of cast padding and continue distally.

b. Carefully incorporate only the unaffected leg into the abdominal portion, using a figure-of-8 technique around the hip (Figure 14-12).

c. Do not yet incorporate the long leg cast of the affected extremity.

16. Apply longitudinal traction to the affected extremity to achieve reduction if necessary.

17. Incorporate the long leg cast into the abdominal cast (Figure 14-13).

a. Use a figure-of-8 technique.

b. Ensure that the perineum remains exposed.

18. Mold the cast (Figure 14-14):

a. Place one palm on the lateral aspect of the thigh immediately proximal to the fracture site.

b. Place the other palm on the medial aspect distal to the fracture site.

c. Mold the cast into valgus.

19. Create a side strut for the affected extremity if plaster is being used.

a. Take a roll of plaster and create a splint that is 10 layers thick extending from the mid abdomen to the mid thigh.

b. Apply the splint obliquely along the inferior lateral buttock area to act as a strut.

20. Apply a broomstick or bar of fiberglass to span both legs. Incorporate the strut and the bar into the spica cast with an additional roll of fiberglass (Figure 14-15).

21. Complete the cast (Figure 14-16):

a. Use colored fiberglass for a “Hollywood roll” if desired.

b. Remove towels from the abdomen.

c. Remove the child from the spica table.

d. Trim away any excess casting material.

Figure 14-4

Figure 14-5

Figure 14-6

Figure 14-7

Figure 14-8

Figure 14-9

Figure 14-10

Figure 14-11

Figure 14-12

Figure 14-13

Figure 14-14

Figure 14-15

Figure 14-16

Long-leg splint

Overview

The design of the long-leg splint is identical to that of the AO splint described later, with a posterior slab and a stirrup, except that each of the slabs traverses the knee and extends to the upper thigh.

Indications for Use

1. Tibial shaft fracture

2. Tibial plateau fracture

3. Distal femur fracture

Precautions

1. As in any other splint that immobilizes the ankle and foot, the position of the foot within the splint is of paramount importance. Do not allow the foot to be in equinus except in the case of very distal tibial shaft fractures where dorsiflexion results in extension at the fracture site.

2. The long-leg splint is placed with the knee in 20 to 30 degrees of flexion.

3. Given the propensity for tibial shaft fractures to become very swollen and the associated high risk for compartment syndrome, Jones’ cotton typically is used.

Pearls

1. Before starting, ensure that adequate analgesia has been achieved, either with intravenous opioids or conscious sedation.

3. It is recommended that cool water be used (to delay plaster setting) and that all three plaster slabs be prepared in water prior to application of the splint. This approach reduces the amount of time the patient needs to be elevated and thus reduces patient discomfort. It also reduces the amount of work that needs to be done by the assistants.

4. For high-energy injuries, we prefer to use Jones’ cotton in place of regular cotton cast padding.

5. Use of a “mega-ACE” bandage that is 11 yards long makes securing this splint much more manageable because it eliminates the need for multiple elastic bandages.

6. Premade 45-inch plaster slabs typically are an appropriate length for all three slabs necessary for this splint.

Figure 14-17

Equipment

1. 4- or 6-inch stockinette

2. Jones’ cotton and/or 6-inch cast padding

3. 4-, 5-, or 6-inch plaster

4. 6-inch elastic or self-adherent bandage

5. 2-inch silk tape

Detailed Technique

1. Measure the length of the splint using plaster (Figures 14-18 and 14-19):

a. Use the contralateral uninjured side if necessary.

b. A single measurement will be taken using the lateral aspect.

c. Measure from the medial malleolus, circle around the foot, and extend until the upper aspect of the lateral thigh is reached.

2. Roll out the plaster.

a. The plaster slab should be 10 to 12 sheets thick.

b. Alternatively, use 45 × 5 inch prefabricated slabs.

3. Prepare the plaster in the usual fashion. Use the standard technique of wetting and laminating (see Chapter 12).

a. Use water that is slightly cooler than that used for other splints.

b. Hang the plaster strips from the stretcher or lay them out on a bed sheet.

4. Place a padded crutch beneath the mattress on the stretcher so that only a foot of the top of the stretcher remains visible (Figure 14-20).

5. Position the patient:

a. The patient is supine with his or her pelvis halfway onto the crutch (Figure 14-21). Make sure the patient and the crutch are secure.

b. Allow the limb to hang down, or support it by placing the patient’s foot on your thigh (Figure 14-22). If assistants are available, they can elevate the limb.

6. Apply Jones’ cotton or regular cast padding (Figure 14-23):

a. If using Jones’ cotton, start at metatarsal heads and wrap in a circumferential fashion proximally to the mid thigh with minimal overlap.

b. If using standard padding, begin proximally or distally depending on your preference.

8. Perform a reduction maneuver if required.

9. Definitively secure the splint with an ACE wrap (Figures 14-27 and 14-28):

a. Start at the foot and extend proximally.

b. Secure the end with silk tape.

10. Mold the splint:

a. At this point, assistants are no longer necessary.

b. The limb is taken by the surgeon, the foot is placed on the thigh, and an axial load is applied to ensure the foot is not in equinus.

(1) This position naturally places the knee at approximately 30 degrees of flexion.

(2) Perform either a supramalleolar mold (Figure 14-29) or a supracondylar mold (Figure 14-30) or both.

Figure 14-18

Figure 14-19

Figure 14-20

Figure 14-21

Figure 14-22

Figure 14-23

Figure 14-24

Figure 14-25

Figure 14-26

Figure 14-27

Figure 14-28

Figure 14-29

Figure 14-30

Long leg cast

Indications for Use

Tibial shaft fractures

Precautions

1. The position of the foot in the plaster is of paramount importance.

a. The equinus position is defined as a foot plantarflexed beyond neutral.

b. If the foot is left in an equinus position for a prolonged period, the Achilles tendon becomes contracted and ankle stiffness ensues.

2. At the anterior aspect of the ankle, do not allow edges of the cast padding to lay immediately within the joint line.

a. Allowing edges of the cast padding to lay immediately within the joint line will create wrinkling and can lead to skin breakdown in this very fragile area.

b. Span the area by having the mid-point of the cast padding roll directly over the ankle flexion crease; by doing so, the cast padding will be slightly tented above the joint line and will not be in direct contact with the skin, thus reducing the risk of skin breakdown.

Pearls

1. Before starting, ensure that adequate analgesia has been achieved, either with intravenous opioids or conscious sedation. Occasionally, long leg casts are placed under general anesthesia in the operating room to allow for fluoroscopic-guided reduction and maximum patient comfort.

2. Two techniques may be used for application of a long leg cast:

a. Application of a short leg cast and then completion of the upper leg portion is the easiest technique to perform.

b. Application of a long leg cast by starting at the thigh and continuing distally in one sitting creates the strongest cast.

3. Application of a long leg cast is difficult; having the aid of an assistant makes it easier. If an assistant is unavailable, use the following technique:

a. Carefully pad a standard walking crutch.

b. Lower the guard rail on the stretcher.

c. Place the crutch under the mattress of the stretcher at the level of the hip, with one third sticking out on the affected side (see Figure 14-20).

d. Have the patient rest his or her buttocks on the crutch.

e. Position the limb with your leg.

Equipment

1. 4- or 6-inch stockinette

2. 4- or 6 inch cast padding.

3. 4 or 6-inch plaster or fiberglass

Detailed Technique

1. Prepare a stockinette by cutting two pieces:

a. One piece is for the proximal portion at the thigh.

b. One piece is for the distal portion at the foot.

2. Position the stockinette (see Figure 14-22):

a. Place one stockinette over the proximal thigh.

b. Place the other stockinette with equal lengths centered over the metatarsal heads.

3. Position the patient.

a. Place a padded crutch beneath the mattress on the stretcher so that only 1 foot of the top of the stretcher remains visible (see Figure 14-20).

b. The patient is supine with his or her pelvis halfway onto the crutch (see Figure 14-21). Make sure the patient and the crutch are secure to prevent a fall.

c. Allow the limb to hang down or support it by placing the patient’s foot on your thigh (see Figure 14-22). If available, an assistant can elevate the limb.

d. If the patient is anesthetized, bring the patient to the edge of the bed and drape the extremity over the side with an assistant holding the leg.

5. Create a cast padding cuff (see Chapter 12) for the metatarsal heads (Figure 14-35). This cuff should form a V at the lateral aspect of the foot to allow for the cascade of the digits.

6. Fold down the end of the stockinette at the foot (Figure 14-36) and thigh (Figure 14-37).

7. Prepare the plaster. Use the standard technique of wetting and laminating (see Chapter 12).

8. Apply the plaster.

a. Start at the thigh and work distally (Figure 14-38). Use the standard technique of laminating while rolling (see Chapter 12).

b. Be vigilant about the position of the foot.

c. The foot can easily fall into equinus (Figure 14-39).

d. Additional thickness over the plantar aspect of the foot can be achieved by adding several precut strips.

9. Allow the cast to dry before lowering the leg.

Figure 14-31

Figure 14-32

Figure 14-33

Figure 14-34

Figure 14-35

Figure 14-36

Figure 14-37

Figure 14-38

Figure 14-39

Cylinder cast

Indications for Use

1. Patellar fractures

2. Patellar dislocations

Precautions

Be sure to pad the malleoli thickly to avoid pressure sores on the ankle and to limit distal migration of the cast (Figure 14-40).

Figure 14-40

Pearls

Have the patient stand with his or her knee in slight flexion, sufficiently straight to walk on but bent enough to be comfortable.

Equipment

2. Cast padding

Detailed Technique

1. Prepare a stockinette by cutting it into two pieces:

a. One piece is for the proximal portion at the thigh.

b. One piece is for the distal portion at the lower leg.

2. Position the patient and place the stockinette segments (Figure 14-41):

a. Place one stockinette over the proximal thigh.

b. Place the other over the malleoli.

3. Wrap the extremity in cast padding.

a. Start at either end and wrap circumferentially (Figure 14-42).

(1) Use a standard 50% overlap technique (see Chapter 12).

(2) Two layers of wrapping are sufficient.

b. Span the joint line with cast padding at the posterior aspect of the knee (see aforementioned precautions) (Figure 14-43).

c. Apply a thick cuff of cast padding at the ankle (Figure 14-44).

4. Create a cast padding cuff (see Chapter 12) for the malleoli (Figure 14-45).

5. Fold down the end of the stockinette at the ankle (Figure 14-46) and thigh (Figure 14-47).

6. Prepare the plaster. Use the standard technique of wetting and laminating (see Chapter 12).

7. Apply the plaster:

a. Start at the thigh and work distally (Figure 14-48).

b. Use the standard technique of laminating while rolling (see Chapter 12).

c. Be vigilant about the position of the knee.

d. Additional thickness behind the knee can be achieved by adding several precut strips.

8. Apply the mold (Figure 14-49).

Figure 14-41

Figure 14-42

Figure 14-43

Figure 14-44

Figure 14-45

Figure 14-46

Figure 14-47

Figure 14-48

Figure 14-49

AO splint

Indications for Use

1. Ankle fractures

2. Pilon fractures

Precautions

1. The position of the foot in the plaster is of paramount importance.

a. The equinus position is defined as a foot plantarflexed beyond neutral.

b. If the foot is left in an equinus position for a prolonged period, the Achilles tendon becomes contracted and ankle stiffness ensues.

2. Swelling is a significant concern for ankle fractures; the degree of swelling often worsens after 2 to 3 days.

a. A bulky cotton padding (variously known as Sir Robert Jones’ cotton, Bulky Jones cotton, and Red Cross cotton) can be applied below the plaster slabs to allow the splint to accommodate the swelling.

b. The medial and lateral slabs should be kept slightly posterior on the leg to prevent them from joining at the anterior aspect. If they join both posteriorly and anteriorly, this position creates a circumferential cast construct.

Pearls

1. Many ankle fractures are reduced with use of the Quigley maneuver. By having the patient keep his or her leg in extension during the Quigley maneuver, the ankle will naturally be kept out of equinus.

2. For instances in which a reduction maneuver is not used, two techniques can be used to keep the foot out of equinus:

b. The patient is kept supine while the splint is applied. The hip is slightly flexed, the knee is bent to 90 degrees, and the foot is placed on the surgeon’s chest. Axial pressure is applied until the plaster has set. This technique typically is used with unconscious patients.

3. When applying Jones’ cotton, splitting it in half width-wise is useful. Halving the thickness of the cotton by splitting it longitudinally also is possible.

4. Using cool water and preparing all three plaster slabs in water prior to application of the splint is the easiest technique to use and eliminates the need for an assistant.

5. When applying the medial and lateral slabs, always start at the proximal aspect of the limb. If the splint is long, it can simply be carried up the other side.

Equipment

1. 4-inch stockinette

2. 4- or 6-inch cast padding

3. 4- or 6-inch plaster

4. 4- or 6-inch elastic or self-adherent bandage

5. 2-inch silk tape

Basic Technique

1. Patient positioning:

a. If the Quigley maneuver is used: The patient is supine on a stretcher with his or her leg elevated by traction.

b. If the supine or sitting technique is used: The patient is supine or sitting on a stretcher with the knee and lower leg off the bed.

c. If the prone technique is used: The patient is prone on a stretcher with the knee flexed to 90 degrees.

2. Where to start:

a. Metatarsal heads

3. Where to finish:

a. Tibial tubercle

4. Where to mold for ankle fracture:

a. Distal to the lateral malleolus over the calcaneus

b. Immediately proximal to the medial malleolus

Detailed Technique: Application Sitting

1. Perform an intra-articular ankle block, if desired (see Chapter 6).

3. Roll out the plaster.

a. The plaster slab should be 10 to 12 sheets thick.

b. Two different slabs will be created, with the U slab being approximately 25% longer than the posterior slab.

5. Apply cast padding (or Jones’ cotton, if desired) (Figures 14-52, 14-53, and 14-54):

a. Start at either end and wrap in a circumferential fashion from the metatarsal heads to the level of the fibular head and tibial tubercle.

b. Because of the thickness of the Jones’ cotton, very little overlap is necessary.

6. Prepare the plaster in the usual fashion.

a. Use the standard technique of wetting and laminating (see Chapter 12).

b. Prepare both slabs at the same time before application.

c. Water that is slightly cooler than that used for other procedures should be used.

7. Apply the plaster slabs.

a. Begin with the posterior slab (Figure 14-55).

(1) Start at foot and extend proximally.

(2) Fold down excess at the knee if it is encountered.

b. Apply the U slab (Figure 14-56).

(1) Start proximally at the fibular head and extend distally.

8. Overwrap with a single layer of cast padding (Figures 14-57 and 14-58).

9. Definitively secure the splint with an ACE wrap (Figure 14-59):

a. Start at either end and advance to the other end.

b. Secure the end with silk tape or Velcro.

10. Perform molding:

a. Ankle fracture (see Chapter 11)

b. If no reduction is necessary, apply supramalleolar molding (Figure 14-60).

Figure 14-50

Figure 14-51

Figure 14-52

Figure 14-53

Figure 14-54

Figure 14-55

Figure 14-56

Figure 14-57

Figure 14-58

Figure 14-59

Figure 14-60

Short-leg cast

Indications for Use

1. Ankle fractures (nonacute)

2. Achilles tendon rupture (in equinus)

Precautions

1. The position of the foot in the plaster is of paramount importance.

a. The equinus position is defined as a foot plantarflexed beyond neutral.

b. If the foot is left in an equinus position for a prolonged period, the Achilles tendon becomes contracted and ankle stiffness ensues.

c. When a short leg cast is used for an Achilles tendon rupture, 10 to 15 degrees of equinus is desirable, and an optional heel can be built into the cast to facilitate weight bearing in the cast while maintaining equinus (Figures 14-61 and 14-62).

2. At the anterior aspect of the ankle, do not allow edges of cast padding to lay immediately within the joint line.

a. Allowing edges of cast padding to lay immediately within the joint line will create wrinkling and can lead to skin breakdown in this very fragile area.

b. Span the area by having the mid-point of the cast padding roll directly over the ankle flexion crease; by doing so, the cast padding will be slightly tented above the joint line and will not be in direct contact with the skin, thus reducing the risk of skin breakdown.

Figure 14-61

Figure 14-62

Pearls

1. Raise the stretcher as high as it will go to make application of the cast easier.

Equipment

1. 4-inch stockinette

2. 4- or 6-inch cast padding

3. 4- to 6-inch plaster or fiberglass

Basic Technique

1. Patient positioning:

a. The patient is sitting off the end of the bed. Ensure that at least half the thigh is off the bed to allow for space between the leg and the bed.

b. Alternatively, the patient may be placed prone with the knee flexed to 90 degrees.

2. Where to start:

a. Metatarsal heads

3. Where to finish:

a. Tibial tubercle

4. Where to mold:

a. No reduction: supramalleolar mold

b. Ankle fracture:

(1) Distal to the lateral malleolus over the calcaneus

(2) Immediately proximal to the medial malleolus

Detailed Technique

1. Position the patient (Figure 14-63):

a. The patient is sitting upright and the leg is freely off the end of the bed.

b. Make sure the patient is sitting far enough forward so there is sufficient room between the posterior calf and the end of the bed.

2. Prepare a stockinette by cutting it into two pieces:

a. One piece is for the proximal portion at the knee.

b. One piece is for the distal portion at the foot.

3. Position the stockinette segments (Figure 14-64):

a. Place one stockinette segment over the knee with equal lengths on either side.

b. Place the other segment with equal lengths centered over the metatarsal heads.

5. Create two cast padding cuffs (see Chapter 12):

a. Metatarsal heads (see Figure 14-35): This cuff should form a “V” at the lateral aspect of the foot to allow for the cascade of the digits.

b. Tibial tubercle (Figure 14-67): This cuff can be circular.

6. Fold down the two ends of stockinette (see Figure 14-36).

7. Prepare the plaster. Use the standard technique of wetting and laminating (see Chapter 12).

8. Apply the plaster.

a. Start at the tibial tubercle and work distally (Figure 14-68). Use the standard technique of laminating while rolling (see Chapter 12).

(1) Be vigilant about the position of the foot (Figure 14-69).

(2) Additional thickness over the plantar aspect of the foot can be achieved by adding several precut strips, if desired.

9. Apply molding or perform a reduction as needed.

10. Split the cast if necessary.

Figure 14-63

Figure 14-64

Figure 14-65

Figure 14-66

Figure 14-67

Figure 14-68

Figure 14-69

Patellar tendon bearing (PTB) cast

Indications for Use

Low tibial shaft fractures

Precautions

1. The position of the foot in the plaster is of paramount importance.

a. The equinus position is defined as a foot plantarflexed beyond neutral.

b. If the foot is left in an equinus position for a prolonged period, the Achilles tendon becomes contracted and ankle stiffness ensues.

2. At the anterior aspect of the ankle, do not allow edges of cast padding to lay immediately within the joint line.

a. Allowing edges of cast padding to lay immediately within the joint line will create wrinkling and can lead to skin breakdown in this very fragile area.

b. Span the area by having the mid-point of the cast padding roll directly over the ankle flexion crease; by doing so, the cast padding will be slightly tented above the joint line and will not be in direct contact with the skin, thus reducing the risk of skin breakdown.

Pearls

1. Raise the stretcher as high as it will go to make application of the cast easier.

Equipment

1. 4-inch stockinette

2. 4-inch cast padding

3. 4- or 6-inch plaster

Detailed Technique

1. Position the patient as for a short leg cast.

a. The patient is sitting upright and the leg is freely off the end of the bed.

b. Make sure the patient is sitting far enough forward so there is sufficient room between the posterior calf and the end of the bed.

2. Prepare a stockinette by cutting one piece of the stockinette for the distal portion at the foot.

3. Position the stockinette.

5. Create two cuffs of cast padding (see Chapter 12):

a. Metatarsal heads: This cuff should form a “V” at the lateral aspect of the foot to allow for the cascade of the digits.

b. Patellar tendon (Figures 14-71 and 14-72): Make sure that knee motion is unimpeded.

6. Fold down the end of the stockinette.

7. Prepare the plaster. Use the standard technique of wetting and laminating (see Chapter 12).

8. Apply the plaster:

a. Start at the patellar tendon and apply a strip of 2-inch plaster over the anterior-proximal shin (Figure 14-73).

b. Staying out of the popliteal fossa, wrap circumferential plaster to cover the strip of plaster (Figure 14-74).

c. Continue wrapping as per a short leg cast. Use the standard technique of laminating while rolling (see Chapter 12).

(1) Be vigilant about the position of the foot.

(2) Additional thickness over the plantar aspect of the foot can be achieved by adding several precut strips, if desired.

9. Apply supramalleolar molding.

10. Make sure the cast does not limit knee flexion or extension (Figures 14-75 and 14-76).

Figure 14-70

Figure 14-71

Figure 14-72

Figure 14-73

Figure 14-74

Figure 14-75

Figure 14-76

Related

Handbook of Splinting and Casting Mobile Medicine Series