ORTHOPEDIC NURSING

VINCENT L. ORAIZ JOHN LOZADA

CAST

Cast Care Introduction

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The function of a cast is to rigidly protect an injured bone or joint. It serves to hold the broken bone in proper alignment to prevent it from moving while it heals. Casts may also be used to help rest a bone or joint to relieve pain that is caused by moving it (such as when a severe sprain occurs, but no broken bones). Different types of casts and splints are available, depending on the reason for the immobilization and/or the type of fracture. Casts are usually made of either plaster or fiberglass material.

Fracture Types and Healing

A fractured bone is the same as a broken bone. Most fractures happen because of a single and sudden injury. The diagnosis of a fracture is usually made with an x-ray film.
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A simple (or closed) fracture has intact skin over the broken bone. An open fracture is also called a compound fracture. This means that a cut or wound exists on the skin near the broken bone. If the cut is very severe, the edges of the bone may be seen coming out from the wound. A stress fracture can result from many repeated small stresses on a bone. Microscopic fractures form and, if not given time to heal, can join to form a stress fracture. These types of fractures are usually seen in athletes or soldiers who perform repetitive vigorous activities. A pathologic fracture happens with minimal or no injury to an abnormal bone. This is usually caused by an underlying weakness or problem with the bone itself, such as osteoporosis or tumor.

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When a bone is fractured, it may require a reduction or realignment to put the ends of the fracture back into place. A doctor will do this by moving the fractured bone into alignment with his or her hands. If a bone has a fracture but is not out of position or deformed, no reduction is necessary. When the ends of the bone are aligned, the injured bone requires support and protection while it heals. A cast or splint usually provides this support and protection. Many factors affect the rate at which a fracture heals and the amount of time a person needs to wear a cast. Ask a doctor how much time the specific fracture will take to heal.

Types of Casts and its Indication
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Airplane Cast Humerous and shoulder joint with compound fracture Basket Cast Severe leg trauma with open wound or inflammatin Body Cast Lower dorso-lumbar spine affection Boot Leg Cast Hip and femoral fracture Cast Brace Fracture of the femur (distal curve) with flexion and extension Collar Cast Cervical affection Cylindrical Leg Cast Fractured patella Delbit Cast Fractured tibia or fibula Double Hip Spica Mold Cervical affection with callus formation Frog Cast Congenital hip dislocation Functional Cast Fractured humerous with abduction and adduction Hanging Cast Fractured shaft of the humerous Internal Rotator Splint post hip operation Long Arm Circular Cast Fractured radius and ulna Long Arm Posterior Mold Fractured radius and ulna with compound affectation Long Leg Circular Cast Fractured tibia and fibula Long Leg Posterior Mold Fractured tibia and fibula with compound affectation

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Minerva Cast Upper dorsal/cervical spine affectation Munster Cast Fractured radius/ulna with callus formation Night Splint Post polio Pantalon Cast Pelvic bone fracture PTB (Patella Tendon Bearing) Cast Fractured tibia and fibula with callus formation Quadrilateral (Ischial Weight Bearing Cast) Shaft of femur with callus formation Rizzer’s Jacket Scoliosis/cervico thoraco lumbar Short Arm Circular Cast Fractured in the wrist and fingers Short Arm Posterior Mold Wrist and finger fractures with compound affectation Short Leg Circular Cast Ankle and foot fracture Short Leg Posterior Mold Ankle and foot fracture with compound affectation Shoulder Spica Humerous anf shoulder joint affectation Single Hip Spica Hip and 1 femur fractured Single Hip Spica Mold Pelvic fracture with callus formation 1 and ½ Hip Spica Hip and femur fracture 1 and ½ Spica Mold Hip and femur with compound affectation

How Casts Are Applied
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Many different sizes and shapes of casts are available depending on what body part needs to be protected. A doctor decides which type and shape is best for each person. Cast application
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Before casting material is applied (plaster or fiberglass), a "stockinette" is usually placed on the skin where the cast begins and ends (at the hand and near the elbow for a wrist cast). This stockinette protects the skin from the casting material. After the stockinette is placed, soft cotton batting material (also called cast padding or Webril) is rolled on. This cotton batting layer provides both additional padding to protect the skin and elastic pressure to the fracture to aid in healing. Next, the plaster or fiberglass cast material is rolled on while it is still wet. The cast will usually begin to feel hard about 10-15 minutes after it is put on, but it takes much longer to be fully dry and hard. Be especially careful with the cast for the first 1-2 days because it can easily crack or break while it is drying and hardening. It can take up to 24-48 hours for the cast to completely harden. A plaster cast is made from rolls or pieces of dry muslin that have starch or dextrose and calcium sulfate added. When the plaster gets wet, a chemical reaction happens (between the water and the calcium sulfate) that produces heat and eventually causes the plaster to set, or get hard, when it dries. A person can usually feel the cast getting warm on the skin from this chemical reaction as it sets. The temperature of the water used to wet the plaster affects the rate at which the cast sets. When colder water is used, it takes longer for the plaster to set, and a smaller amount of heat is produced from the chemical reaction. Plaster casts are usually smooth and white. Fiberglass casts are also applied starting from a roll that gets wet. After the roll gets wet, it is rolled on to form the cast. Fiberglass casts also get warm and harden as they dry.

Plaster casts
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Fiberglass casts
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Fiberglass casts are rough on the outside and look like a weave when they dry. Some fiberglass casts may even be colored.

Nursing Consideration in Cast Application
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Check’s for the doctor’s order. Prior to cast application, the procedure should be well-explained to the patient as well as the family. Explain to the patient and his or her relative to need for placing the affected part of the body in a cast. Show illustration of the type of the cast to be applied to help them visualize “how is it” and “what it is for”. Inform them of the approximated duration for the body to remain in cast, the limitation and the discomfort arising from immobilization. Paln shold be made to allow the period of immobilization less boresome and frustating. Skin preparation is done. If possible a good cleansing bath and shampoo maybe given to the patient. The affected part ne cleansed thouroghly with soap and water or with detergent and driend. If there is a wound have it dressed accordingly. Padding is applied first: either stokinette, web-roll or padding. Make sure that it is fits smoothly, without wrinkles which may cause abrade skin and lead to skin breakdown Plaster-filled bandages are submerged in a bucket of clean water, one at a time. The excess water is removed, and the bandage is applied to encircle the part. During application, support the extremity from underneath using the palms of the hands in such a way that pressure is not applied in one area only.

Nursing Care
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Handle wet cast with palms of the hands, not the fingers. Doing so may cause flattering or indentions in the cast that might cause pressure problems. Cast should be allowed to air dry. Elevate the cast on one to two pillows during drying. Observe ‘hot spot” and musty color. These are signs and symptoms of infection. Maintain skin integrity. Do neurovascular checks:
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Skin color Skin temperature Sensation Mobility Pulse

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Assess for vascular occlusion Adhesive tape petals reduce irritation at cast edges.

Cast Care Instruction
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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 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 your child to move his/her fingers or toes to promote circulation Do not use the abduction bar on the cast to lift or carry the child.

Ice and Elevation
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A doctor may want the person to use ice to help decrease the swelling of the injured body part. (Check with a physician before using ice.) To keep the cast from becoming wet, put ice inside a sealed plastic bag and place a towel between the cast and the bag of ice. Apply ice to the injury for 15 minutes each hour (while awake) for the first 24-48 hours. Try to keep the cast and injured body part elevated above the level of the heart, especially for the first 48 hours after the injury occurs. Elevation will help to decrease the swelling and pain at the site of the injury. Propping the cast up on several pillows may be necessary to help elevate the injured area, especially while asleep.

Taking Care of Your Cast
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Always keep the cast clean and dry. If the cast becomes very loose as the swelling goes down, call the doctor for an appointment, especially if the cast is rubbing against the skin. Cover the cast with a plastic bag or wrap the cast to bathe (and check the bag for holes before using the bag a second time). Some drug stores or medical suppliers have cast covers—plastic bags with Velcro straps to seal out water for protection during bathing. Avoid showers; use the bathtub and hang the covered cast or injured body part outside of the tub while you bathe. Do not lower the cast down into the water. If a fiberglass cast gets damp, dry it (make sure it dries completely). Because a fiberglass cast allows air through it, a hairdryer on the cool setting should do the trick (do not try to dry it using a hairdryer without a cool setting—you could burn yourself). If you have any trouble getting the cast dry, call a doctor to find out if the cast needs to be replaced. If the cast gets wet enough that the skin gets wet under the cast, contact the doctor. If the skin is wet for a long period of time, it may break down, and infection may occur. Sweating enough under the cast to make it damp may cause mold or mildew to develop. Call the doctor if mold or mildew or any other odor comes from the cast. Do not lean on or push on the cast because it may break. Do not put anything inside the cast. Do not try to scratch the skin under the cast with any sharp objects; it may break the skin under the cast. Do not put any powders or lotions inside the cast. Do not trim the cast or break off any rough edges because this may weaken or break the cast. If a fiberglass cast has a rough edge, use a metal file to smooth it. If rough places irritate the skin, call the doctor for an adjustment. An arm sling may be needed for support if the cast is on the hand, wrist, arm, or elbow. It is helpful to wrap a towel or cloth around the strap that goes behind the neck to protect the skin on the neck from becoming sore and irritated. If the cast is on the foot or leg, do not walk on or put any weight on the injured leg, unless the doctor allows it. If the doctor allows walking on the cast, be sure to wear the cast boot (if given one by the doctor). The boot is to keep the cast from wearing out on the bottom and has a tread to keep people in casts from falling. Crutches may be needed to walk if a cast is on the foot, ankle, or leg. Make sure the crutches have been adjusted properly before leaving the hospital or the doctor's office.

How a Cast Is Removed
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Do not try to remove the cast. When it is time to remove the cast, the doctor will take it off with a cast saw and a special tool.
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A cast saw is a specialized saw made just for taking off casts. It has a flat and rounded metal blade that has teeth and vibrates back and forth at a high rate of speed. The cast saw is made to vibrate and cut through the cast but not to cut the skin underneath. After several cuts are made in the cast (usually along either side), it is then spread and opened with a special tool to lift the cast off. The underlying layers of cast padding and stockinette are then cut off with scissors.

After a cast is removed, depending on how long the cast has been on, the underlying body part may look different than the other uninjured side.
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The skin may be pale or a different shade. The pattern and length of hair growth may also be different. The injured part may even look smaller or thinner than the other side because some of the muscles have weakened and have not been used since the cast was put on.

If the cast was over a joint, the joint is likely to be stiff. It will take some time and patience before the joint regains its full range of motion.

Complications
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Many potential complications are related not only to wearing a cast but also to the healing of the underlying fracture. Immediate complications Compartment syndrome
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Compartment syndrome is a very serious complication that can happen because of a tight cast or a rigid cast that restricts severe swelling. Compartment syndrome happens when pressure builds within a closed space that cannot be released. This elevated pressure can cause damage to the structures inside that closed space or compartment—in this case, the muscles, nerves, blood vessels, and other tissues under the cast. This syndrome can cause permanent and irreversible damage if it is not discovered and corrected in time. Signs of compartment syndrome
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Severe pain Numbness or tingling Cold, pale, or blue-colored skin Difficulty moving the joint or fingers and toes below the affected area.

If any of these symptoms occur, call the doctor right away. The cast may need to be loosened or replaced.

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A pressure sore or cast sore can develop on the skin under the cast from excessive pressure by a cast that is too tight or poorly fitted. Delayed complications Healing problems
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Malunion: The fracture may heal incorrectly and leave a deformity in the bone at the site of the break. (Union is the term used to describe the healing of a fracture.) Nonunion: The edges of the broken bone may not come together and heal properly. Delayed union: The fracture may take longer to heal than is usual or expected for a particular type of fracture.

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Children are at risk for a growth disturbance if their fracture goes through a growth plate. The bone may not grow evenly, causing a deformity, or it may not grow any further, causing one limb to be shorter than the other. Arthritis may eventually result from fractures that involve a joint. This happens because joint surfaces are covered by cartilage, which does not heal as easily or as well as bone. Cartilage may also be permanently damaged at the time of the original injury.

When to Call Your Doctor

Check the cast and the skin around the edges of the cast everyday. Look for any damage to the cast, or any red or sore areas on the skin. Call the doctor immediately if any of the following happen:
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The cast gets wet, damaged, or breaks. Skin or nails on the fingers or toes below the cast become discolored, such as blue or gray. Skin, fingers, or toes below the cast are numb, tingling, or cold. The swelling is more than before the cast was put on. Bleeding, drainage, or bad smells come from the cast.

Severe or new pain occurs

Synonyms and Keywords
 cast

care, cast, casting, splint, plaster, fiberglass, immobilization, fracture management, broken bone, fractured bone, simple fracture, closed fracture, compound fracture, open fracture, stress fracture, pathologic fracture, stockinette, cast padding, Webril, plaster cast , fiberglass cast, compartment syndrome, cast sore, malunion, nonunion, delayed union, arthritis

References
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1. Amendola A, Twaddle B. Compartment syndromes. In: Browner BD, Jupiter JB, Levine AM, Trafton PG, eds. Skeletal Trauma. 2nd ed. Philadelphia, Pa: WB Saunders Co; 1998:365-389. 2. Latta L, Sarmiento A, Zych G. Principles of nonoperative fracture treatment. In: Browner BD, Jupiter JB, Levine AM, Trafton PG, eds. Skeletal Trauma. 2nd ed. Philadelphia, Pa: WB Saunders Co; 1998:237-266. 3. Rosen P, Barkin RM, eds. Emergency Medicine: Concepts and Clinical Practice. 4th ed. St. Louis, Mo: Mosby-Year Book; 1998:620-622. 4. Salter RB. Fractures and joint injuries. In: Textbook of Disorders and Injuries of the Musculoskeletal System. 2nd ed. Baltimore, Md: Lippincott Williams & Wilkins; 1983:349426. 5. Simon R, Koenigsknecht S. Fracture principles. In: Emergency Orthopedics: The Extremities. 3rd ed. Norwalk, Conn: Appleton & Lange; 1996:3-20, 517-36. 6. Simon RR, Koenigsknecht SJ. Treatment of fractures. In: Emergency Orthopedics: The Extremities. 2nd ed. Norwalk, Conn: Appleton & Lange; 1987:7-15. 7. Tintinalli JE, Menkes JS. Immobilization techniques. In: Tintinalli JE, Kelen GD, eds. Emergency Medicine: A Comprehensive Study Guide. 5th ed. New York, NY: McGraw-Hill; 2000:1747-1753.

Authors and Editors

Author: Jennifer L Brown, MD, Assistant Residency Director, Staff Physician, Clinical Assistant Instructor, Department of Emergency Medicine, State University of New York at Buffalo. Coauthor(s): Richard S Krause, MD, Program Director, Clinical Assistant Professor, Department of Emergency Medicine, State University of New York at Buffalo. Editors: Scott H Plantz, MD, FAAEM, Research Director, Assistant Professor, Department of Emergency Medicine, Mount Sinai School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, Pharmacy, eMedicine; Jerry Balentine, DO, Professor of Emergency Medicine, New York College of Osteopathic Medicine; Medical Director, Department of Emergency Medicine, Saint Barnabas Hospital

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