Definition

A cast is a rigid dressing used to immobilize a fractured bone or soft tissue injury. It is made
of strips impregnated with plaster or fiberglass material. The injured area is first covered
with a layer of padding made of cotton or synthetic materials to protect the skin from
irritation. The plaster or fiberglass strips are then dipped in water and applied over the
padding to form the cast.

Purpose

In general, casts are applied to injured limbs to support and protect the bones and soft
tissue. The cast helps to reduce the pain, swelling, and muscle spasms following the injury.
If the bone is broken, the cast holds the fractured bone ends in correct alignment during the
healing process. A cast, because of its rigid properties, will also provide protection from
further injury. Body casts are used to prevent movement of the vertebrae of the back and
may be used after a traumatic injury to the spine or a surgical repair of the vertebrae.

Precautions

For health professionals

Wet casts must be handled carefully, using only the palms of the hands, because a wet cast
can be dented or compressed if handled too much after application. Dents or compression of
the cast can cause pressure or irritation to the skin beneath the dressing, which may
develop sores or ulcers.

Patients in a hip cast or body cast should be repositioned every two hours during the first 24
hours to allow even drying of the cast and every two hours when awake thereafter to avoid
developing pressure sores on the skin.

For patients

The use of crutches may be recommended for patients with a leg cast or a sling for patients
with an arm cast for use during the first 24-48 hours. Patients should be instructed to rest
and keep the affected limb elevated on a pillow as much as possible during the first 24
hours.

Description
Materials

Of the two types of materials used for the hard supportive layer of cats, fiberglass has the
advantages of being lighter, longer-wearing, and better able to "breathe" than plaster.
Fiberglass is less trouble for the patient, because plaster casts are more likely to lose their
shape if they become wet than fiberglass casts. It is also easier for x rays to penetrate
fiberglass than plaster casts. Plaster, on the other hand, is less expensive and is easier to
mold or shape to the body. A plaster cast will harden in 15–30 minutes but takes 24–48
hours to dry completely. A fiberglass cast will dry faster, in 15–30 minutes, but the force of
the patient's full body weight may cause the cast to crack in the first 24 hours after
application.

Application

Casts are usually applied by physicians or orthpedic technicians, with the assistance of other
health professionals. If the bone is broken, the physician will first place the fractured bone
into alignment. Stockinette cut to size is applied to the limb and then cast padding (cotton
batting) is wrapped around the extremity. The physician dips the casting material in water,
squeezes out excess water, and then applies it wet over the cast padding to form the cast.
After applying the cast, the physician will roll the stockinette over the edges of the cast to
provide smooth edges at the top, bottom and any openings on the cast. The patient's toes
and fingertips are not covered by the cast. The cast is then usually placed on pillows
elevated above the patient's heart level for 15–20 minutes to dry.

Preparation

A health professional will assist the patient in removing any clothing that will be difficult to
pull over the cast later. The patient is positioned with the affected extremity resting on a
pillow. The skin around the affected area is gently cleansed and thoroughly dried. The
patient may be given medication for pain as directed by the physician. After the cast has
been applied, extra pillows are placed under the cast to elevate it. The patient should be
kept warm and comfortable while the cast is drying. It is helpful to explain to the patient
that the cast will feel warm at first but then cool and damp as the material dries.

Aftercare

Aftercare includes measuring the patient for crutches or a sling as appropriate. In addition,
patients should be given aftercare instructions as follows:
  The cast should be kept dry. Water weakens plaster casts and may cause skin
irritation beneath the cast. The patient should use two layers of plastic to keep the
cast dry while bathing or showering.
 To decrease swelling and pain in the first 24–48 hours, the patient should place
crushed ice in a plastic bag, covered with a pillow case or towel, on the cast over the
injury every 15 minutes per hour while awake.
 Dirt, sand, or powder should be kept away from the inside of the cast. Cast boots
can be purchased to cover the foot area of a leg cast.
 Padding should not be pulled out of the cast. In addition, the patient should not stick
coat hangers, knitting needles, or similar items inside the cast in order to scratch
itchy skin.
 The patient should not break off or trim the edges of the cast without consulting the
physician.
 The cast should be inspected regularly. If it develops cracks or soft spots, the
physician should be notified.
 The patient should never attempt to remove the cast. The physician will remove the
cast at the appropriate time with a special saw that cuts through the casting material
but will not damage skin.

Complications

Compartment syndrome

A serious complication that can occur after cast application is known as compartment
syndrome. This is a rare phenomenon that occurs when a cast is too tight. As the affected
limb swells, the cast acts as a closed compartment, tightly compressing the nerves
and blood vessels. Compartment syndrome can cause permanent nerve damage or loss of
limb due to decreased circulation and oxygen to the tissue. Patients should be instructed to
call the physician at once if any of the following signs or symptoms appear:

 increased pain combined with the feeling that the cast is too tight
 numbness and tingling in the hand or foot
 burning and stinging sensations
 excessive swelling in the part of the limb below the cast
 inability to actively move the toes or fingers

Compromised healing
Another complication of cast application is that the injury may not heal properly. In some
cases the bone endings are set incorrectly, producing a deformity; or do not unite at all.
Either may require surgical correction. Delayed union of the bone endings may occur in
elderly or malnourished patients; their casts may need to remain in place for a longer period
of time.

Results

Cast application is an effective treatment for a fractured bone, serious soft tissue injury or
surgical joint repair. Casts generally remain in place until bone healing occurs (four to six
weeks). The physician will order x rays to monitor bone healing. X rays can be done through
the cast. As bone healing occurs and the limb strengthens, the physician may replace the
initial cast with a shorter one or a splinted cast that can be removed for bathing. When the
cast is removed, the patient's skin will appear dry and the muscles of the limb may be
slightly wasted. Skin care with moisturizers and special exercises to regain muscle strength
or to relieve joint stiffness may be ordered by the physician.

Health care team roles

Cast application is usually performed by a physician but may be performed by a specially

trained orthopaedic technician under the direction of the physician. The licensed nurse will
assess the inpatient patient in a medical setting with a newly casted limb for the first 24-48
hours after cast application. In the outpatient setting, the licensed nurse will observe the
patient for the first hour after cast application and instruct the patient and patients family
about cast care, signs and symptoms of complications and the importance of follow-up visits
with the physician for routine reassessment and cast removal.

KEY TERMS

Compartment syndrome—A potentially serious complication of cast application, caused by

pressure of the cast on the nerves and blood vessels in the injured limb.
Casts
1
-
Externally applied structure that hold bone in one position
2
-
Is a rigid device applied to immobilize the injured bones and
promote healing. it is applied to immobilize the joint above and below
the fractured bone so that the bone won't move during healing . these
are applied on clients who have relatively stable fractures
Purpose of cast
:
Immobilize parts of the body
Hold bone fragments in reduction (reduction is bringing the fractured
on its anatomical position

Apply uniform compression

Stabilize joint

Correct deformities

Support weakened limb

Permit early weight bearing on affected side

Definition
Traction is the use of a pulling force to treat muscle and skeleton
disorders.
Purpose
Traction is usually applied to the arms and legs, the neck, the
backbone, or the pelvis. It is used to treatfra ctures, dislocations, and
long-duration muscle spasms, and to prevent or correct deformities.
Traction can either be short-term, as at an accident scene, or long-
term, when it is used in a hospital setting.
Traction serves several purposes:
•
it aligns the ends of a fracture by pulling the limb
into a straight position
•
it ends muscle spasm
•
it relieves pain

•
it takes the pressure off the bone ends by relaxing
the muscle
There are two main types of traction: skin traction and skeletal
traction. Within these types, many specialized forms of traction have
been developed to address problems in particular parts of the body.
The application of traction is an exacting technique that requires
training and experience, since incorrectly applied traction can cause
harm.
Positioning the extremity so that the angle of pull brings the ends of
the fracture together is essential. Elaborate methods of weights,
counterweights, and pulleys have been developed to provide the
appropriate force while keeping the bones aligned and preventing
muscle spasm. The patient's age, weight, and medical condition are all
taken into account when deciding on the type and degree of traction.
Precautions
People who are suffering from skin disorders or who are allergic to tape
should not undergo skin traction, because the application of traction
will aggravate their condition. Likewise, circulatory disorders
or varicose veins can be aggravated by skin traction. People with an
inflammation of the bone (osteomyelitis) should not undergo skeletal
traction.
Description
Skin traction
Skin traction uses five-to seven-pound weights attached to the skin to
indirectly apply the necessary pulling force on the bone. If traction is
temporary, or if only a light or discontinuous force is needed, then skin
traction is the preferred treatment. Because the procedure is not
invasive, it is usually performed in a hospital bed.
Weights are attached either through adhesive or nonadhesive tape, or
with straps, boots, or cuffs. Care must be taken to keep the straps or
tape loose enough to prevent swelling and allow good circulation to the
part of the limb beyond the spot where the traction is applied. The
amount of weight that can be applied through skin traction is limited
because excessive weight will irritate the skin and cause it to slough
off.
Specialized forms of skin traction have been developed to address
specific problems. Dunlop's traction is used on children with certain

fractures of the upper arm, when the arm must be kept in a flexed
position to prevent problems with the circulation and nerves around
the elbow. Pelvic traction is applied to the lower spine, with a belt
around the waist. Buck's skin traction is used to treatkne e
injuries other than fractures. The purpose of this traction is to stabilize
the knee and reduce muscle spasm.
Skeletal traction
Skeletal traction is performed when more pulling force is needed than
can be withstood by skin traction; or when the part of the body
needing traction is positioned so that skin traction is impossible.
Skeletal traction uses weights of 25-40 pounds.
Skeletal traction requires the placement of tongs, pins, or screws intothe bone so that the weight is
applied directly to the bone. This is aninvasive procedure that is done in an operating room under
general,regional, or local anesthesia.
Correct placement of the pins is essential to the success of the
traction. The pin can be kept in place several months, and must be
kept clean to prevent infection. Once the hardware is in place, pulleys
and weights are attached to wires to provide the proper pull and
alignment on the affected part.
Specialized forms of skeletal traction include cervical traction used for
fractures of the neck vertebrae; overhead arm traction used for certain
types of upper arm fractures; and tibia pin traction used for some
fractures of the femur, hip, or pelvis.
Preparation
X rays are done prior to the application of both forms of traction, and
may be repeated during treatment to assure that the affected parts
are staying in alignment and healing properly. Since the insertion of
the anchoring devices in skeletal traction is a surgical procedure,
standard preoperative blood and urine testing are done, and the
patient may meet with an anesthesiologist to discuss any health
conditions that might affect the administration of anesthesia.
Aftercare
Aftercare for skin traction involves making sure the limb stays aligned,
and caring for the skin so that it does not become sore and irritated.
The patient should also be alert to any swelling or tingling in the limb
that would suggest that the limb has been wrapped too tightly.
CASTS AND MOLDS -Acas t is a rigid external immobilizing device that is molded to the contours of the body. - It is
used specifically to: • immobilize a reduced fracture • correct a deformity • apply uniform pressure to underlying
soft tissue • support or stabilize weakened joints - Generally, casts permit mobilization of the patient while
restricting movement of a body part. - The condition being treated influences the type and thickness of the cast
applied. Generally, the joints proximal and distal to the area to be immobilized are included in the cast. However,
with some fractures, cast construction and molding may allow movement of a joint while immobilizing a fracture. -
Various types of cast include the following: •Short-arm cast – extends from below the elbow to the palmar crease,
secured around the base of the thumb. If the thumb is included, it is known as a thumb spica or gauntlet cast •
Long-arm cast – extends from the axillary fold to the proximal palmar crease. The elbow usually is immobilized at a
right angle. • Short-leg cast – extends from below the knee to the base of the toes. The foot is flexed at a right
angle in a neutral position. • Long-leg cast – extends from the junction of the upper and middle third of the thigh
to the base of the toes. The knee may be slightly flexed. • Walking cast – a short or long-leg cast reinforced for
strength • Body cast – encircles the trunk • Shoulder spica cast – a body jacket that encloses the trunk, shoulder
and elbow • Hip spica cast – encloses the trunk and a lower extremity. A double hip spica cast includes both legs. -
Cast are usually made of either plaster or fiberglass materials •Fiberglass Casts -Composed of water-activated
polyurethane materials that have the versatility of plaster but are lighter in weight, stronger and more durable
than plaster - Water-resistant -Consist of an open-weave, nonabsorbent fabric impregnated with cool water-
activated hardeners that bond and reach full rigid strength in minutes - A newly applied fiberglass should not be
placed on a plastic surface. *** Heat is given off (an exothermic reaction) while the cast is applied. The heatgiven
off during this reaction can be uncomfortable, and the nurse should prepare the patient for the sensation of
increasing warmth. - It must be handled with the palms of the hands and not allowed to rest on hard surfaces or
sharp edges. *** While the cast is setting, it can be dented. Cast dents may press on the skin, causing irritation and
skin breakdown.

-When the cast is wet, the patient is instructed to shake or drain water out of it. *** Thorough drying is important
to prevent skin breakdown. •Plaster Casts - Less costly and achieve a better mold than fiberglass casts - Not as
durable as fiberglass casts and take longer to dry - Also cause an exothermic reaction - Requires 24 to 72 hours to
dry completely, depending on the thickness and the environmental drying conditions - A wet plaster cast appears
dull and gray, sounds dull on percussion, feels damp and smells musty. - A dry plaster cast is white and shiny,
resonant to percussion, odorless and firm. GENERAL NURSING MANAGEMENT OF A PATIENT IN A CAST: •Assess
the patient’s general health, presenting signs and symptoms, emotional status, understanding of the need for the
device, and condition of the body part to be immobilized. •Assess the neurovascular status (ie, neurologic and
circulatory functioning) of the body part and degree and location of swelling, bruising, and skin abrasions. •Inform
the patient about the underlying pathologic condition and the purpose and expectations of the prescribed
treatment regimen. •Prepare the patient for the application of the cast by describing the anticipated sights,
sounds, and sensations (eg, heat from the hardening reaction of the fiberglass or plaster). •Evaluate pain
associated with the musculoskeletal condition. Ask the patient to indicate the exact site and to describe the
character and intensity of the pain to help determine its cause. •Encourage toe or finger exercises to maintain the
function of joints that are not immobilized and to stimulate circulation. •Clean the skin thoroughly and treat it as
prescribed. •Observe the patient for systemic signs of infection; odors from the cast and purulent drainage staining
the cast. •Monitor circulation, motion and sensation of the affected extremity. Assess the fingers or toes of the
affected extremity and compare them with those of the opposite extremity