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plasters and mterials

1. PLASTER OF PARIS AND CASTS DR.BHOSALE SUMIT ORTHOPEDICS JUNIOR RESIDENT 1

2. INTRODUCTION POP – Plaster of Paris First applied in the treatment of fractures over 150 years ago Proven indispensable in the non-operative management of not only musculoskeletal injuries but other ailments requiring immobilization as well. Its use however isn’t without risk. Sound knowledge and properly-honed skills in its application and care are necessary to maximize outcome.

3. Casting properties of POP were first observed when a house built on gypsum burnt down in Paris. It was found after rain fall, that the footprints in the mud were caked upon drying. First used in fracture care by Antonius Mathijsen , A Dutch army surgeon in 1852.

4. PHYSIOCHEMICAL PROPERTIES OF POP POP is CaSO4 .½H2O in its anhydrous form impregnated in gauze which has been pre-strengthened with starch or dextrose. Obtained from heating gypsum to 120°C. The hydration of CaSO4. ½H2O converts it from powder form to crystalline form which gives rise to cast. This is the process of setting and is an EXOTHERMIC REACTION, CaSO4 .½H2O + 3/2H2O → CaSO4 .2H2O + Heat

5. CH E MIC A L FO R MU L A : 2CaSO 4 ·½H 2 O + 3H 2 O ==> 2CaSO 4 ·2H 2 O + heat Hemi hydrated calcium sulphate (POP) Hydrated calcium sulphate (GYPSUM) PLASTER OF PARIS

6. POP incorporates 20% of the water it soaks up, the remaining 80% is lost during drying. Setting time – time taken to convert from powder form to crystalline form • Average time is 3 – 10 mins • Reduced by high temp, salt solution, borax solution, addition of resin • Increased by low temp, sugar solution

7. Se t ting time : T ime t a k en t o chan g e f r o m p ow de r f or m t o crystalline form. D r ying time : T ime t a k en t o chan g e f r o m c r y s t alline f or m t o anhydrous form. Average setting time : 3-9 minutes. Average drying time : 24-72 hours.

8. AN IDEAL CAST Suitable for direct application Easy to mould Non toxic Unaffected by water Transparent to x-rays Quick setting Able to transmit air Strong but light weight Non-inflammable Non-messy Long shelf life Cheap

9. CLASSIFICATION Based on pattern of application: Slab : POP encloses partial circumference Cast : POP encloses full circumference Spica : B andage that is applied in successive V-shaped crossings, includes trunk and one or more limbs (Hip spica ) Brace : Splintage which can allow motion at adjacent joints

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

11. 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.

12. 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

13. 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

14. 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

15. 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.

16. Indications Fractures Ligament injuries Reduced dislocations Musculoskeletal infections Deformity correction Severe soft tissue injuries esp. across joints Post tendon repair Post-operatively to augment internal fixation Inflammatory conditions – arthritis, tenosynovitis

17. RULES GUIDING POP USE POP should be applied by the surgeon Procedure requires an assistant A guide to appropriate size: • Arm & forearm – 4” • Wrist – 4” • Thigh & leg – 8” • Ankle & foot – 6”

18. RULES GUIDING POP USE Apply POP one joint above and below Joint should be immobilized in functional position Padding should be adequate esp. over bony prominences e.g. olecranon, ulnar styloid, patella, fibular head, malleoli, heel. POP shouldn’t be too tight or too loose The plaster should be of uniform thickness throughout Check neurovascular status after cast application Do check x-ray for acceptability of reduction

19. PADDING : Padding should be from distal to proximal with 50% overlap. Extra over elbows and heels. One should be generous over bony prominences . Always pad between digits when splinting hands/ feet or when doing buddy strapping. Not to be applied tightly- danger of ischemia !!

20. Two person team

21. . Positioning of the limb

22. STOCKINET It p r o t e c ts ski n and ma k es the band g e appli c a tion to l o o k nifty. To be applied on the skin before the padding is done. Always cut the stockinet longer than the splint to be applied. Available in various width . Not to be used in FRESH TRAUMA.

23. Application of the padding

24. TECHNIQUE Materials • POP bandage • Crepe bandage (for slabs) • Casting gloves • Basin of water • Bandage scissors • Padding • Sheets • Stockinete • Adhesive tape

25. TECHNIQUE Prepare injured site • Fracture is reduced and assistant holds limb in position of function, in a manner that is unobtrusive to the application of cast • Stockinete is measured, extending 10cm beyond determined limits of cast, and threaded over limb.

26. TECHNIQUE Wool padding is applied gently and snugly, starting from distal to proximal with 50% overlap between successive turns, extending 2-3cm beyond edges of splint Padding is applied generally in 2 layers, but may be increased where there are bony prominences or if significant swelling is anticipated Padding sizes: hand: 2”, rest of upper limb: 3-4” foot: 3”, rest of lower limb: 4-6”

27. POP APPLICATION POP to be used is dipped completely with both hands into tepid or slightly warm water and held there till bubbling stops Prior to this, for slabs, the required length is measured and layered. It is then brought out and lightly squeezed to get rid of excess water If a slab is to be created, the wet plaster is kept on flat surface and the hand is run from one end to another to get rid of air bubbles which may cause slab to be brittle and the layers to separate when dry. 12-14 layers for upper limb and 14-16 layers for lower limb would suffice

28. For slabs POP slab is applied and molded onto the limb contours Molding is only with palms Stockinette & padding are rolled over the edge of slab and crepe bandage is applied from distal to proximal Slabs may be used alone or to reinforce casts For cast POP is applied in distal to proximal with 50% overlap POP is applied snugly, compressing padding thickness by 50% The padding is rolled over and the final turns of POP are rolled over it

29. Above Elbow An above elbow plaster cast or slab is applied from knuckles of hand (distal palmar crease anteriorly] and covers lower two thirds of arm Below Elbow While distal extent is same as above, proximally the plaster ends below elbow crease. Above Knee Distal extent is up to metatarsophalangeal joints and proximally it covers lower two thirds of thigh . Below Knee Distal extent is same, proximal extent ends below knee.

30. POP PRECAUTIONS Where swelling is anticipated use a slab instead of cast, if a cast must be used then it should be well-padded POP applied postoperatively may have to be split as swelling may be significant ( e.g post-tourniquet release, inflammatory edema)

31. POP REMOVAL Slabs are removed by cutting the bandage, carefully avoiding nicking the skin For casts – Using shears » Heel of the shears must lie between plaster and skin, avoiding bony prominences » Avoid cutting over concavities » The route of the shears should lie over compressible soft tissue » The lower handle should be parallel to the plaster – Using electric saw » Do not use unless there’s wool padding » Do not use over bony prominences » The cutting mov’t should be up and down not lateral » Do not use blade if bent, broken or blunt

32. Cast cutting shears Electric saw

33. AFTERCARE Following POP application, check neurovascular status and check reduction by x-rays. Counsel the patient on signs of neurovascular compromise – excessive pain, excessive swelling, bluish or whitish discoloration of digits Reinforce all cracks and weak areas with more POP locally Limb elevation reduces swelling, pain and risk of too tight cast Check if the POP is restricting movement Ensure that all joints not immobilized by cast have full range of motion Any area of localized pain should be windowed as it may be a developing pressure sore The patient should be reviewed in 1 – 2 weeks and x-rays done to reaffirm maintenance of reduction

34. CAST CARE INSTRUCTIONS Keep the cast clean & dry Routinely check the cast for cracks or breaks Do not scratch the skin under the cast by inserting objects inside the cast Do not put powder or lotion inside the cast Encourage the patient to move his fingers or toes to promote circulation In case of itching, apply ice packs or place hair dryer (cool air) against one end to draw air in through it Any area of localized pain should be windowed as it may be a developing pressure sore

35. WHEN TO COME BACK TO HOSPITAL Cast is too tight Develops fever Increased pain Increased swelling above or below the cast Complaints of numbness or tingling Drainage or foul odour from the cast Cold fingers/toes Cant move fingers/toes

36. C OM P LIC A TI O NS O F P O P Due to tight cast Pain Pressure sores – The patient’s complaints of a painful cast should never be ignored, and the cast should be changed promptly. Often, this may reveal an area of early skin pressure or irritation that could progress to full-thickness skin loss. Compart m e n t s ynd r om e and the r esulting sequ elae V olkmann's Ischaemic contracture. Peripheral nerve injuries

37. Due to improper applications : Joint stiffness and malposition of limb. Plaster blisters and sores. Due to plaster allergy : Allergic contact dermatitis – The skin symptoms of irritation were all mild and temporary. Quaternary ammonium compound BENZALKONIUM CHLORIDE is the allergen responsible for plaster of Paris-induced allergic contact dermatitis

38. Disuse Atrophy and Muscle Weakness – Muscles that do not function when under cover of plaster will atrophy Not only can this result in cast loosening, but there may also be functional loss. Motion and isometric exercises should be encouraged. Prolonged non–weight-bearing treatment in a cast can also result in disuse osteopenia , which can complicate recovery. Typically, radiographic features include loss of trabecular pattern, a speckled or mottled appearance of the periarticular surface, and a generalized “ WASHED-OUT” appearance

39. When a limb is put into POP and the joints immobilized for a long period joint stiffness , muscle wasting and osteoporosis are unavoidable. This can be reduced to a minimum by the early use of functional braces, isometric exercise and early weight-bearing. These in turn promote a rapid retrieval of function.

40. FRACTURE DISEASE : A constellation of symptoms and physical changes has been called “fracture disease.” Prolonged immobilization, especially in a nonfunctional cast, can lead to a vicious cycle of pain, swelling, and unresolved edema . Edema fluid is a proteinaceous exudate that will congeal and g e ts c o n v er t ed t o a g el a tin o u s m at erial and depo s i t ed as a s c ar tissue around joints and tendons causing joint stiffness, contracture and tendon adhesions. Muscle atrophy, brawny skin /induration, and osteoporosis follow R e fl e x s y m p a th e tic d y s t r op h y m a y s o metimes o c c u r and further complicate the picture

41. PLASTER DISEASE When a limb is put into plaster and the joints are immobilized for a long period of time, joint stiffness, muscle wasting and osteoporosis are unavoidable. This syndrome can be reduced to a minimum by the early use of functional braces, isometric exercises and early weight bearing, which in turn promote early retrieval of function.

42. CAST SYNDROME : Cast syndrome is a rare complication that is seen related to hip spica cast The syndrome occurs due to arteriomesenteric duodenal obstruction , and it is a result of excessive abdomen and chest coverage. Symptoms are severe, and if left untreated, can be potentially lethal. Compression of the third part of the duodenum between the lumbar spine and the aorta posteriorly and the mesentry and vessels anteriorly. This syndrome is precipitated by recumbency and increased lumbar lordosis. Avoiding constrictive body casts that increase lumbar lordosis prevents cast syndrome. Nausea, epigastric fullness, and regurgitation should be c arefully evaluated.

43. CONTRAINDICATIONS Open fractures Impending compartment syndrome Neurovascular compromise Reflex sympathetic dystrophy Skin infection or ulcers Swelling of the limb Allergy to cast material Comminuted fractures

44. ALTERNATIVES TO POP POP with melamine resin Fiber glass

45. FIBER GLASS CAST A plaster made from reinforced polymer of a plastic matrix reinforced by fine fiber of glass. Also called Glass-reinforced plastic (GRP) or Glass fiber reinforced plastic (GFRP) Fiberglass bandages are usually impregnated with polyurethane Mostly used in those cases where healing process has already begun

46. FIBRE G LA SS CAST : A fiberglass cast is a lighter, synthetic alternative to the more traditional plaster version. It is created by padding the extremity with cotton or waterproof padding material, followed by wrapping several layers of knitted fiberglass bandages impregnated with a water-soluble, quick- setting resin

47. Advantages : Short setting time Immediate weight bearing Strong but weighs light Radiolucent Water resistance Wicks moisture better. Disadvantages : High cost Can’t be applied over wet wounds or immediately after trauma Difficult to remove Leaves sharp edges Less mouldable

48. 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

49. SLAB : Slab is a temporary splint made up of half by POP and half by bandage roll. Used in initial stages of fracture treatment, during first aid and to immobilize the limbs post operatively. Steps in application of slab – Slab is measured into required length For upper extremities use 8-10 layers and for lower extremities use 12-15 layers or upto 20 depending on size of the person Trimmed to the requirement of of the area of application

50. Slab held carefully at both ends and immersed completely in tepid water. Lift out and momentarily bunch up at an angle to expel excess water. Consolidate the layers of the slab to remove excess of air as retained air causes reduction of plaster strength. Slab is positioned and smoothened out with the hands so that the slab fits closely to the contours of the limb. Wet bandage is applied to avoid tightening from shrinkage after coming in contact with the slab.

51. Below Elbow Slab: Indications – Wrist fractures Metacarpal fractures Colle’s fracture

52. Above elbow slab in elbow flexion : Indications Fracture both bones forearm Supracondylar # humerus of extension type Unstable proximal radius or ulnar # Above elbow slab in elbow extension : Indications Olecranon # Supracondylar # humerus of flexion type.

53. U SLAB OR COAPTATION SLAB : Indications : For Proximal and shaft of humerus fractures. Applied to the medial and lateral aspects of the arm, encircling the elbow and overlapping the shoulder. Utilizes dependency traction and hydrostatic pressure to effect fracture reduction

54. Below knee slab Indications: Ankle fractures and dislocations post reduction Tarsal and Meta tarsal fractures. Position : Proximal end – upto tibial tuberosity. Distal end – upto MTP joints of foot. Foot in neutral position.

55. Above Knee Slab Indications Proximal and mid shaft Tibial fractures. Supra condylar # of femur Proximal end – as high in the groin as possible Distal End – to MTP joints of foot Knee in 15 degrees flexion . Foot in neutral position .

56. What is cast index? The Cast Index (CI) is   the ratio of sagittal to coronal width from the inside edges of the cast at the fracture site .   What is gap index? The gap index is a measure of poor moulding and excessive padding applied before plaster application.

57.  REFERENCES Bedside clinics in orthopedics-Upendra Kumar Stewart Essential Orthopedics- Maheshwari Campbell’s Operative Orthopedics

58. THANK YOU