Cast and immobilization techniques in orthopaedics by Dr O.O. Afuye

Cast, similar in function to splints are used to immobilize broken bones. The principles of its application and cast care most be followed for effectiveness.

1. Cast and Immobilization Techniques in Orthopaedics Dr. O.O. Afuye

2. Outline Introduction History Cast types Materials and equipment Principles of cast application Advantages of casting Disadvantages of casting Conditions that benefit from immobilization Removal Complications Conclusion References

3. Introduction Immobilization refers to the process of holding a joint or bone in place with a splint, cast, or brace. This is done to prevent an injured area from moving while it heals. Casts are generally used to immobilize a broken bone . An  orthopedic cast , or simply  cast , is a shell, frequently made from plaster or fiberglass, encasing a limb (or, in some cases, large portions of the body) to stabilize and hold anatomical structures, most often a broken bone(or bones), in place until healing is confirmed. It is similar in function to a splint.

4. History The earliest methods of holding a reduced fracture involved using splints . Ancient Greeks used waxes and resin to create stiffened bandages Roman Celsus AD 30 described how to use splints and bandages stiffened with starch Arabian Doctors used lime derived from sea shells and albumen from egg whites to stiffen bandages Italian school of Salemo (20 th century) recommended bandages hardened with flour and egg mixture Medieval European bonesetters used casts made of egg white, flour and animal fat Ambroise Pare(1517-1590) used artificial limbs, made casts of wax, cardboard, cloth and parchment that hardened as they dried

5. Dominique Jean Larrey (1768-1842) Concluded that undisturbed wound had facilitated healing. Also stiffened bandages using camphorated alcohol, lead acetate and egg whites beated in water Louis Seutin (1793-1865) – Seutin’s bandage amidonnee –consisted of cardboard splints and bandages soaked in starch solution 19 th century- Velpeau substituted Dextrin for starch Consul William Eton described immobilization of patient with gypsum plaster (POP) Antonius Mathijsen (1805-1878)- developed a method of POP application

6. Cast Types Upper extremity casts Lower extremity casts Cylinder casts Body casts EDF (Elongation, Derotation , Flexion)casts Spica cast

7. Cast type Upper Extremity Casts Type location uses Short Arm Cast Applied below the elbow to the hand. Forearm or wrist fractures. Also used to hold the forearm or wrist muscles and tendons in place after surgery. Long arm cast Applied from the upper arm to the hand. Upper arm, elbow, or forearm fractures. Also used to hold the arm or elbow muscles and tendons in place after surgery. Arm cylinder cast Applied from the upper arm to the wrist To hold the elbow muscles and tendons in place after a dislocation or surgery.

8. Cast type Loaction Uses Shoulder spica cast Applied around the trunk of the body to the shoulder, arm, and hand. S houlder dislocations or after surgery on the shoulder area. Minerva cast Applied around the neck and trunk of the body. After surgery on the neck or upper back area

9. Lower extremity Type of cast Location Uses Short leg cast Applied to the area below the knee to the foot L ower leg fractures, severe ankle sprains/strains, or fractures. Also used to hold the leg or foot muscles and tendons in place after surgery to allow healing. Long Leg cast Applied from the upper thigh to the ankle Knee, or lower leg fractures, knee dislocations, or after surgery on the leg or knee area

10. Type of cast Location Uses Unilateral hip spica cast Applied from the chest to the foot on one leg. Thigh fractures. Also used to hold the hip or thigh muscles and tendons in place after surgery to allow healing. One and one-half hip spica cast Applied from the chest to the foot on one leg to the knee of the other leg. A bar is placed between both legs to keep the hips and legs immobilized Thigh fracture. Also used to hold the hip or thigh muscles and tendons in place after surgery to allow healing Bilateral long leg hip spica cast Applied from the chest to the feet. A bar is placed between both legs to keep the hips and legs immobilized. Pelvis, hip, or thigh fractures. Also used to hold the hip or thigh muscles and tendons in place after surgery to allow healing

11. Type of cast Location Uses Short leg hip spica cast Applied from the chest to the thighs or knees To hold the hip muscles and tendons in place after surgery to allow healing Abduction boot cast Applied from the upper thighs to the feet. A bar is placed between both legs to keep the hips and legs immobilized. To hold the hip muscles and tendons in place after surgery to allow healing.

12. Materials and equipment Adhesive tape (to prevent slippage of elastic wrap used with splints ) Elastic bandage (for splints) Bandage scissors Basin of water at room temperature (dipping water) Casting gloves (necessary for fiberglass) Padding Plaster or fiberglass casting material Sheets, underpads (to minimize soiling of the patient's clothing) Stockinette Cast saw and spread

13. Plaster fibreglass Cost Lower higher Moldability excellent average Strength average excellent Weight heavier lighter Curing period 48–72 hours under 30 minutes Radiolucency poor good Water resistance poor excellent Skin complications easily washes off skin and clothes gloves are mandatory, resin stains clothes and bonds to skin for days Allergic reaction very low slightly higher Monovalve spreads easily spreads but recoils; needs a wedge to maintain opening

14. Principles of cast application Pre- cast applications Indications Clinical evaluation Investigation Preparation Material needed Templating Soft bands Cast layers Informed consent Reduction and manual deformity corrections

15. Cast application Maintain reduction during application Avoiding dimple on the cast Ensure adequate layering of soft band and cast Moulding to correct deformity or redisplacement Joint above and joint below the fracture Ensure cast not too tight . ( Px protection and comfort, Px Position, Stokinette , cast padding, water, Exotherm , Cast, Cast Tape, Rolling, molding,soft spots) Px = Patient

16. Post cast applications principles Ensure no compartment syndrome Bivalve if sign of CS is noted Check x-ray (Evaluate Px neurovascular status and range of motion)

17. Window Wound care Investigating a complaint like a pressure sore Checking a pulse Breathing window in a body cast Ultrasound bone stimulator

18. Casts are wedged to correct for unwanted angulation of long bones, joints, or the spine that have already been casted . Open wedge Closed wedge Trimming Cast Conversion

19. Factors affecting the timing for cast setting Factors that speed setting times Higher temperature of dipping water Use of fiberglass Reuse of dipping water Factors that slow setting times Cooler temperature of dipping water Use of plaster

20. Rule of thumb heat is  inversely  proportional to the setting time and   directly  proportional to the number of layers used.

21. Cast care Keep the cast clean and dry. Check for cracks or breaks in the cast. Rough edges can be padded to protect the skin from scratches. Do not scratch the skin under the cast by inserting objects inside the cast. Can use a hairdryer placed on a cool setting to blow air under the cast and cool down the hot, itchy skin. Never blow warm or hot air into the cast.

22. Do not put powders or lotion inside the cast. Cover the cast while your child is eating to prevent food spills and crumbs from entering the cast. Prevent small toys or objects from being put inside the cast. Elevate the cast above the level of the heart to decrease swelling. Encourage to move his or her fingers or toes to promote circulation. Do not use the abduction bar on the cast to lift or carry the child.

23. Use a diaper or sanitary napkin around the genital area to prevent leakage or splashing of urine. Place toilet paper inside the bedpan to prevent urine from splashing onto the cast or bed. Keep the genital area as clean and dry as possible to prevent skin irritation.

24. Advantages of casting Main stay in treatment of most fractures Provides more effective immobilization Protect the injury Prevent further injury Decrease pain

25. Disadvantages Requires more skill More time to apply High risk of complication from improper application

26. Conditions that benefit from immobilization Fractures Sprains Severe soft-tissue injuries Reduced joint dislocations Inflammatory conditions: arthritis, tendinopathy , tenosynovitis Deep laceration repairs across joints Tendon lacerations Postoperative immobilization Px : obtunded or comatose multitrauma patient, the patient under anesthesia, the very young patient, the developmentally delayed patient, and the patient with spasticity.

27. Complications Immediate: Compartment syndrome Pain Heat injury Hypersensitivity reactions Late : Delayed union Malunion Non-union Pressure sores & skin breakdown Infections Joint stiffness Neurologic injury

28. Follow-up and length of immobilization Patient education: elevation of injured extremity (decrease pain and swelling) Cast care and precautions Check for and report signs of compartment syndrome Report: Fever, pain, swelling, pressure, numbness/tingling, drainage/foul odour, cool/cold fingers or toes

29. Follow-up time and length of immobilization varies Depends on: site of injury Type Stability of injury Patient characteristics: age, accessibility, compliance Initial follow-up: within 1-2weeks after application Injury must be assessed, treated and management individualized.

30. Cast saw Manually operated shears: paediatric/ px affected by noise of saw Zip stick can be used Cast-cutting procedures: Monovalve /univalve or bivalve Position Px Prepare Px and earn his/her trust Inspect the cast Plan the cuts strategically Stabilize the cast and begin cutting Release the cast

31. Conclusion Cast and splints serve to immobilize orthopaedic injuries. They promote healing, maintain bone alignment, diminish pain, protect the injury and help compensate for surrounding muscular weakness Proper application technique, vigilance for complications and timely follow-up are essential Improper or prolonged application can increase the risk of complication from immobilization

32. References Boyd A.S., Benjamin. H.J., Asplund . C.(2009) Principles of Casting and Spllinting . American Family Physician. Brown. S.A., Radja.F . (2015). Orthopaedic immobilization techniques. Sagamore Publishing. 1-23 https://www.sagamorepub.com/sites/default/files/2018-07/orthogalley1.pdf Cast types and maintenance Instructions. Standford Children’s Health. https://www.stanfordchildrens.org/en/topic/default?id=cast-types-and-maintenance-instructions-90-P02750 Matthew.H ., Kenneth.N . J. (2008) Cast and Splint Immobilization: Complications. Journal of the American Academy of Orthopaedic Surgeons. 16(1). 30-40 Smith and Nephew. The History and Function of Plaster of Paris in Surgery

33. THANK YOU