Complications of casting

Dr Collin Looi
Clinical Lecturer and Orthopaedic Surgeon
Department of Orthopaedics
Faculty of Medicine and Health Sciences
Universiti Putra Malaysia
Lecture Outline

▪Introduction
▪ Key concepts
▪ Prevention, Intervention and Management strategies

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Introduction
•Casting is a time trialed, well-known form of
immobilization/splintage used in Orthopaedics
•Unfortunately, over the last 3 decades, with the
advent of internal fixation, Orthopaedic
residents/surgeons have less exposure to proper
training on proper use of casts (casts are
routinely applied by cast room technicians,
medical assistants)1
•The true incidence of cast complications is
unknown. Hence the importance of highlighting
this potential problem1

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Well-known Complications
▪ Acute
▪ Thermal injury
▪ Allergy
▪ Compartment syndrome
▪ Peripheral nerve compression
▪ Vascular compression
▪ Loss of reduction/displacement of fracture
▪ Cast saw burns
▪ Chronic
▪ Pressure sores
▪ Immobility
▪ Joint stiffness
▪ DVT
▪ Disuse osteopenia
▪ Anxiety/Depression
▪ Infection

So on and so forth……

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Key concepts

 Prevention is better than cure

 Awareness is key
1. Knowledge of potential parameters that contribute to complications (Cast
material and application technique)
2. Identifying potential risks/patients at risk
3. Identifying signs and symptoms
4. Early intervention and management of complications

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Casting material and application
technique
 Casting material
 Plaster of Paris vs Fiber glass
Advantages Disadvantages

Plaster of Paris Less risk of sores/compression • Higher risk of thermal injury

(more pliable) • Poor resistance to water
• Low strength-to-weight ratio
(heavier/thicker casts)

Fiberglass Lighter and stronger Higher risk of pressure

sores/cuts/compression due to
rigidity

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 Casting material and application
technique
 Application technique
 Prevention of thermal injury
 Dip water temperature <50 degrees3
 Ensure cast is not too thick (>24 ply)2
 Avoid placing a curing cast on a pillow2
 Avoid reinforcing a curing cast with a fiber glass
(prevents heat dissipation)1
 Prevention of pressure sores
 Adequate padding especially at bony prominences
 Prevention of compartment syndrome/neurovascular
compression
 Stretch-relaxation technique for fiber glass application
 Ensure there is adequate room for tissue to expand
while ensuring the limb is immobilized with adequate
stability (Cast-index – 0.7)

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Potential risks/patients at risk
•Certain patients are at high-risk for cast related complications1
• Patients unable to communicate (eg. Obtunded, comatosed polytrauma
patient)
• Patients under general/regional anaesthesia (eg. unable to feel/respond to
noxious stimuli)
• Patients with impaired sensation (eg. With central/ peripheral neuropathy)
• Young/developmentally delayed patients
• Patients with spasticity (higher risk of pressure sores)
• Patients with history of allergies to cast materials

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Early prevention, intervention and
management for common complications
 Thermal injury1
▪ Ensure dip water is <50 degrees
▪ Ensure cast is not too thick (<24 ply)
▪ Adhering to manufacturers recommendations
▪ Avoiding practice of curing cast on a pillow2
▪ Remove cast, immobilize with splint and treat
the burn

▪ Allergy
▪ Ensure patient is not allergic to cast material
▪ If allergic, to remove cast material, change to
hypoallergenic padding material and synthetic
cast materials
▪ Refer to dermatologist for further management

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Early intervention and prevention strategies
for some common complications
▪ Compartment syndrome
▪ Orthopaedic emergency
▪ Bivalve the cast/Remove the cast
▪ Reassess condition-> If signs and symptoms
are still present or worsening
▪ To proceed with emergent fasciotomy

▪ Peripheral nerve compression/Vascular

compression
▪ Bivalve the cast

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References
1. Halanski M, Noonan K. Cast and Splint Immobilization: Complications. J Am Acad Orthop Surg.
2008; 16:30-40
2.Gannaway J, Hunter J. Thermal effects of casting materials. Clin Orthop Relat Res. 1983;
181:191-195.
3. Lavalette R, Pope M, Dickstein H. Setting temperatures of plaster casts: The influence of
technical variables. J Bone Joint Surg Am. 1982; 64:907-911.

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Thank you!

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