PLASTER

APPLICATION

PRESENTED BY
DR. FIDEL OKOLI
 OUTLINE
• Case presentation
• Introduction
• History
• Indications of Splinting
• How to apply POP
• Complications
• Follow up
• Conclusion/references
 CASE 1
• A 32 yr old driver of an SUV was involved in
MVA. He was unrestrained and said he lost
control of the vehicle and ran off the road to
hit a lamp post. He was brought into ED via
EHS screaming of pain on the right LL.
• Vitals: P -110; BP- 90/54 mmHg; SPO2-98%
RA.
• How would you approach the mgt of this pt.?
 CASE 2

A 28 yr old man presented to the ED with hx. of painful

swelling of the left arm with limited movement. He
alleged that he was beaten up by 4 men 1 hour prior to
presentation.

His vital signs on presentation: P- 98bpm; BP-

130/78mmHg; SPO2- 97% RA.

How would you manage this patient in the ED?

 Introduction
• POP is made from gypsum - calcium sulfate
dihydrate
• Used to temporarily immobilize fractures,
dislocations, and soft tissue injuries.
• Exothermic reaction when wet - recrystallizes (can
burn patient)
• Warm water - faster set, but increases risk of burns
• Upper extremities - use 8-10 layers
• Lower extremities - 12-15 layers, up to 20 if big
person (increased risk of burn!)
 HISTORY
• The writings of
Hippocrates
discussed in the
mgt. of fractures,
recommended
wooden splints
plus exercise to
prevent muscle
atrophy during
immobilization.
 HISTORY
• The Ancient Egyptians used
wooden splints made of bark
wrapped in linen.
• Ancient Hindus treated
fractures with bamboo splints.
• The Ancient Greeks also used
waxes and resins to create
stiffened bandages.
• The Roman in AD 30,describes
how to use splints and bandages
stiffened with starch
 HISTORY
Arabian doctors used lime derived from sea shells
and albumen from egg whites to stiffen bandages.
The innovation of the modern cast by four military
surgeons:
-Dominique Jean Larrey,

-Louis Seutin,

- Antonius Mathijsen, and

-Nikolai Ivanovich Pirogov

POP dressings were first employed in the treatment of

mass casualties in the 1850s during the Crimean
war.
 How to prepare plaster of
paris
• Plaster of paris is made from crystalline
gypsum by heating in controlled conditions
(120 c – 160 c)

2(CaSO4.2H2O)+Heat 2(CaSO4,1/2H2O)
+3H2O
Gypsum POP + water
• The POP powder then spread onto gauze
bandage which sets to hard cast when
soaked in water
 POP SETTING
• POP rapidly absorbs water which forms
growing solid crystals of CaSO4.2H2O

• 2(CaSO4,1/2H2O)+3H2O 2(CaSO4.2H2O)
+Heat
POP Water Gypsum crystals
• During this time heat is generated(exotherm)
as a result of chemical activity(hydration)
 Stages of setting
• Initial set
• - <10 min
• - crystals become longer and start to
interlock
• - end of the working time
• - if the cast is manipulated after the
initial set it will be weak
• - if immersed in cold water initial set
will be delayed , working time
lengthened
• - in warm water (< 50 c) initial set will
be accelerated
• > 50 c the setting rate will slows,>
100 c no set
• Final set
• -forming a rigid structure around the
gauze mesh
• -heat is generated at this time
• -end of the exotherm period
• - 10 - 45 min
• Hard set
• -crystals are completely locked
together, excess water will be lost by
evaporation
• -strength of the cast increases
considerably during first 24 -72 hrs
• -the plaster is then able to withstand
considerable forces
• - if the cast subsequently absorbs
excess water,it will weaken

• - drying out will be delayed in cold or

moist conditions

• - eccelerated in warm and dry

environment

• - denotes end of the drying out period

 Setting depends on
• The less water is used, the more linear
expansion occurs.

• Potassium Sulphate used as an accelerator

• sodium borate as a retarder

in order that the plaster can be caused to set

more quickly or slowly
 Preparing to place a splint
• Expose the injured extremity
completely before splinting
• Clean, repair, and dress all open
wounds before applying any splint
• Check for neurovascular compromise
• Choose the appropriate size and shape
of splint to be used
• Goal is to cover ½ circumference of the
extremity without overlap
• Prevent stiffness and
loss of function by:

– Preparing extremities
to be Splinted in their
functional position

– Preparing extremities
to be Splinted against
gravity
 Minimize swelling/edema
• Rest, Ice, and Elevate
• Ice-apply to area where there is no plaster
and not more than 15-20 minutes/hr at a
time for first 2 days
– Longer may numb the extremity
– shorter may not affect swelling
• Elevate the limb above the heart level
 PADDING
• To protect skin soft tissue and bony
prominences from pressure and abrasion
and for cast removal

• To protect the skin from thermal injury

during setting

• Over padding will reduce closed fitting of

cast and permits excess movement at #
site resulting in impaired healing
 PRINCIPLES OF CAST
MAKING
• PADDING :
-apply stockinet over the area to be plastered
-then apply orthopedic padding, overlap each
turn by 1/3 in order to secure layers
padding is specially important in:
a) swelling is present/expected
b) limb is thin,bones are superficial
c) when electric cutters are used
• APPLICATION :
get ready equipment and water(25 c-35 c)

Pt in comfortable position and clothing

protected and understand what is going to
happen

if Pt is tense , cast will loose and inefficient

desired position secured and held correctly

bandages of the correct size are immersed in
water at a time , held until bubbling stops

ends are gently squeezed and expel water

(not too much-will become unworkable)

unrolls the wet bandage around the limb in an

even manner , minimum tension directed
towards the centre of the bandage
 only circular and spiral turns , reverse turns
will lead to ridges inside the cast , moulding
done by constant smoothing with wet palm

when the required thickness obtained ,

trim to ensure range of movement at joints
not immobilized(this should be done while the
cast is wet)

Pt is instructed in taking care of the cast

HOW TO APPLY
• For slab
after immersed in water ,immediately
remove , the layers must be pressed
together and bubbles excluded , if this is
not done the layers become brittle when
dry and can separate
 Specific Splints and Orthoses
Upper Extremity Lower Extremity
• Elbow/Forearm • Knee
– Long Arm Posterior – Knee Immobilizer / Bledsoe
– Double Sugar - Tong – Bulky Jones
• Forearm/Wrist – Posterior Knee Splint
– Volar Forearm / Cockup
• Ankle
– Sugar - Tong
– Posterior Ankle
• Hand/Fingers
– Stirrup
– Ulnar Gutter
– Radial Gutter
• Foot
– Thumb Spica – Hard Shoe
– Finger Splints
 Long Arm Posterior Splint
• Indications
– Elbow and forearm injuries:
– Distal humerus fx
– Both-bone forearm fx
– Unstable proximal radius or
ulna fx (sugar-tong better)
• Doesn’t completely eliminate
supination / pronation -either
add an anterior splint or use
a double sugar-tong if
complex or unstable distal
forearm fx.
 Double Sugar Tong
• Indications
– Elbow and forearm fx - 10
prox/mid/distal radius and
ulnar fx.
– Better for most distal
forearm and elbow fx
because limits 90

flex/extension and
pronation / supination.
 Forearm Volar Splint aka ‘Cockup’ Splint
• Indications
– Soft tissue hand / wrist injuries
- sprain, carpal tunnel night
splints, etc
– Most wrist fx, 2nd -5th
metacarpal fx.
– Most add a dorsal splint for
increased stability - ‘sandwich
splint’ (B).
– Not used for distal radius or
ulnar fx - can still supinate and
pronate.
 Forearm Sugar Tong
• Indications
– Distal radius and
ulnar fx.
• Prevents pronation /
supination and
immobilizes elbow.
 Hand Splinting
• The correct position for most hand splints is
the position of function, a.k.a. the neutral
position.
• This is with the the hand in the “beer can”
position (which may have contributed to the
injury in the first place) : wrist slightly
extended (10-25°) with fingers flexed as
shown.
• When immobilizing metacarpal neck
fractures, the MCP joint should be flexed to
90°.
• Have the patient hold an ace wrap (or a beer
can if available) until the splint hardens.
• For thumb fx, immobilize the thumb as if
holding a wine glass.
 Radial and Ulnar Gutter
•Indications
•Fractures, phalangeal and
metacarpal, and soft tissue
injuries of the little and ring
fingers.
•Indications
•Fractures, phalangeal and
metacarpal, and soft tissue
injuries of index and long
fingers.
 Thumb Spica
• Indications
– Scaphoid fx - seen or
suspected (check snuffbox
tenderness)
– De Quervain tenosynovitis.
• Notching the plaster (shown)
prevents buckling when
wrapping around thumb.
• Wine glass position.
Finger Splints

• Sprains - dynamic
splinting (buddy
taping).
• Dorsal/Volar finger
splints - phalangeal
fx, though gutter
splints probably
better for proximal
fxs.
Jones Compression Dressing
- aka Bulky Jones
• Procedure
• Indications – Stockinette and
– Short term immobilization Webril.
of soft tissue and
ligamentous injuries to
– 1-2 layers of thick
the knee or calf. cotton padding.
• Allows slight flexion and – 6 inch ace wrap.
extension - may add posterior
knee splint to further
immobilize the knee.
 Posterior Ankle Splint
• Indications
– Distal tibia/fibula fx.
– Reduced dislocations
– Severe sprains
– Tarsal / metatarsal fx
• Use at least 12-15 layers of
plaster.
• Adding a coaptation splint
(stirrup) to the posterior splint
eliminates inversion /
eversion - especially useful
for unstable fx and sprains.
 Stirrup Splint
• Indications
– Similiar to posterior splint.
– Less inversion /eversion
and actually less plantar
flexion compared to
posterior splint.
– Great for ankle sprains.
– 12-15 layers of 4-6 inch
plaster.
 Other Orthoses
• Knee Immobilizer
– Semirigid brace, many models
– Fastens with Velcro
– Worn over clothing
• Bledsoe Brace
– Articulated knee brace
– Amount of allowed flexion and extension can be adjusted
– Used for ligamentous knee injuries and post-op
• AirCast/ Airsplint
– Resembles a stirrup splint with air bladders
– Worn inside shoe
• Hard Shoe
– Used for foot fractures or soft tissue injuries
 How do you know if the
splint is too tight
• If patient feels numbness, tingling, or increased
pain,

• If the fingers or toes start turning blue

• If the fingers or toes become swollen

 Care of the splint
• Do not get the splint wet. Use plastic bags
to cover the splint while bathing.

• Do not walk on the splint.

• Do not stick anything down the splint to scratch

or itch. This may lead to injury and infection
 Complications
• Burns • Pressure sores
– Thermal injury as plaster dries – Smooth Webril and plaster well
– Hot water, Increased number of • Infection
layers, extra fast-drying, poor
– Clean, debride and dress all
padding - all increase risk
wounds before splint
– If significant pain - remove splint application
to cool
– Recheck if significant wound or
• Ischemia increasing pain
– Reduced risk compared to
casting but still a possibility
– Do not apply Webril and ace
wraps tightly
– Instruct to ice and elevate
Any complaints of
extremity worsening pain -
– Close follow up if high risk for
swelling, ischemia. Take the splint off
– When in doubt, cut it off and look
– Remember - pulses lost late.
and look!
 Follow up
• Instruct patient should return if numbness,
tingling, increased pain and impaired sensation
• Re-evaluate in 48 hours for neurovascular
compromise
5 P’s : pain, pallor, paresthesia, pulselessness,
and paralysis
• Orthopedic evaluation in 7-10 days for casting
 CONCLUSION
• POP application is one of the best method of
temporal immobilization of fractures,
dislocations and soft tissue injury especially
in ED.
• It is important that the ED physician
familiarize him/herself with the methods of
plaster application so as to facilitate timely
and normal union of fractures while
minimizing complications that may arise.
 REFERENCES
• Wheeless’ Textbook of Orthopaedic surgery

• Surgical exposures in orthopaedics: Hoppenfeld

• Orthopedic Principles:A Review

• Jpournal of Surgical Orthopedic advances

• Orthopedic care textbook

Questions?