Principles of Casting and Splinting

1. Principles of Casting and Splinting Naomi N. Shields, M.D. February 8, 2012

2. Introduction Casts and splints Immobilize Position Protect Used for Fractures Sprains Soft tissue and crush injuries

3. Workshop Brief overview Demonstration of Short arm cast or splint Demonstration of cast removal Hands on�don�t forget to remove them from your friends!

4. Principles of Application Avoid wrinkles Even layer cast padding Overlap by � Wrap distal to proximal Avoid tourniquet effect

5. Principles of Application Use palms/flat of hand to mold Avoid fingertips Creates indents and cast sores Rubbing cast well (esp plaster) laminates Avoid burns Hotter water and more layers cast material = HEAT as cast sets up Be careful with young, elderly or insensate pt

6. Supplies Stockinette 2-6� sizes Cut or fold at ankle, elbow, knee to avoid wrinkle Roll up to roll on Synthetic or cotton

7. Supplies Cast padding Synthetic Cotton Gortex Cast material Plaster Fiberglass Polyester Splint material Plaster Fiberglass (OCL, etc)

8. Common UE Splints Volar or short arm Radial Gutter Ulna Gutter Thumb spica Sugar Tong Long arm Commonly used after injury to allow swelling Often utilized after surgery

9. Upper Extremity Splints Pt positioning Supine with shoulder abducted, elbow flexed (hold digits), control forearm rotation Sitting with elbow resting table, thumb and fingers towards ceiling (gives slight dorsal flexion to wrist) Thumb spica Thumb and index in apposition Gutter splints MCP�s FLEXION PIP/DIP�s EXTENSION If reverse VERY difficult to get motion back in digits

10. Application UE splints Position patient Wrap with webril (2-3�) Apply splint material Overwrap with kling or kerlix Apply Ace Mold/Hold til set up Avoid bulk through anterior elbow (especially fractures near elbow � may impair circulation!) Figure 8 wrap at elbow effective

11. Comments re Sugar Tong Controls forearm rotation better then Short arm Keep volar and dorsal edges apart � if touch mid forearm create circumfrential tourniquet For better elbow immobilization � one sugar tong from palm around elbow to dorsum hand � second from axilla around elbow to back of arm

12. UE Casts Short arm cast (SAC) Long arm cast (LAC) Munster Thumb spica

13. Common LE Splints Posterior Splint Posterior with Stirrup Short Leg Compression Long Leg Knee Immobilizer Applications steps like UE May be helpful to position pt prone (esp if heavy pt) Long leg may need reinforcement at knee

14. Common LE Casts Short Leg (SLC) Short Leg Walking (SLWC) Patella Tendon Bearing Long Leg (LLC) Total Contact Cast Cylinder

15. Cast Application Position Patient Apply Stockinette

16. Cast Application In UE casts follow palmar crease for hand function Appose thumb + index In LE casts Don�t get too high into popiteal fossa short leg Consider great and little toes

17. Cast Removal Cast saw vibrates Can CUT skin IF dragged Support saw with hand Go down throught material then come back up and move in direction of cut out of cast � go back down Use spreader to separate cast Bivalve vs univalve Use scissors to cut around top and bottom of top shell to remove Cut longitudinal through stockinette/padding Saw Blade MAY get hot!

18. Cast Complications To tight = PAIN possible compartment syndrome Univalve or bivalve Pressure sores Due to pressure Due to rubbing if loose Skin maceration or fungus

19. Cast Complications Cast Breakdown Under heel � too much padding or not enough material Can crack at junction rolls if rolls not taken full length of cast Cast malposition Loosening If limb swollen when applied, will often need to change 3-7 days later Wet/Damp cast From bathing From sweat

20. Summary Hand out includes cast care guidelines Good idea to give written handout to patients! Also includes some tips on casting in general as well as guidance for various casts It takes time and practice to become proficient at casting. If a patient comes in with a problem cast, evaluate it to see what went wrong, what could be done differently and use these casts to further educate yourself. Now on to hands on��.