Casting & Splinting Workshop

Introduction

This workshop is intended to demonstrate and then allow participants to apply simple splints using casting materials to stabilize injuries.

This is not intended to give any participant expertise in their skills. Participants are encouraged to seek further education and accreditation through professional training.

The precept of "do no harm" and "splint them where they lie" can be very beneficial to laypersons with no training if they simply understand the potential for a significant injury existing and treating it as such in a protective manner until the injury can be definitively diagnosed and managed by a qualified professional.

We do not accredit or acknowledge the individual practice of our participants.

A Brief Explanation of Fractures and Limb Injuries

Where a significant injury is suspected on the ability of pain, swelling, disability or deformation it should be treated with respect until it can be definitely treated.

Boney fractures can exist as many types. Some heal extremely well with no treatment while others will require extensive casting, surgery and rehabilitation.

At the same time soft tissue injuries involving ligaments and tendons may be so disabling as to require splinting or casting to assist healing.

To avoid misdiagnosis it is important to be able to ensure that no significant injury is missed. People who are not experienced in orthopedics are always best to assume an injury may be fractured and treat accordingly. It should also be emphasized that occasionally even X-rays do not always show fractures and each individual must always be reviewed by providers qualified to diagnose and treat these injuries.

Why Splints or Casts?

We immobilize injuries to allow for faster healing. Slight motion will aggravate healing bones and delay in fracture healing. There is some degree of movement even within casts but this is felt to be negligent and acceptable.

The body's response to an injury is usually swelling and tenderness at the site of injury. In the first 24-48 hours this swelling is on going and can increase even if casted. Swelling in an enclosed limb may lead to pressure on nerves and blood vessels causing pain, pallor and pulselessness in the limb the three P's of compartment syndrome .

To help avoid this complication large fractures are managed with " back slabs" or splints manufactured to give support to part of the limb and accommodate swelling.

After a slab is applied the injured limb is reexamined after a number of days.

Once swelling is unlikely to get worse a full circumferential cast is made, making the person more comfortable. Some may use circumferential casts from the very beginning if the injury is small and unlikely to get worse, the patient is accessible for frequent cast changes (and don't mind paying the cost), and is reliable to recognize compartment syndrome symptoms in themselves and report to an emergency department for cast revision if problems occur.

A cast or splint is applied to facilitate that injury to heal, and for no longer.

The orthopedic literature helps give the best amounts of time for immobilizations of each type of fractures.

Reassessment of an injury healing in progress will allow a better assessment of how long a cast is needed.

Over Casting

It is never wrong to splint an injury suspected of being injured. A very general estimate of 4-6 weeks is required for injuries to heal but this widely varies and is additionally dependant on the health of the patient, their occupation and stress.

Although it is often over looked good nutrition and enough rest helps facilitate healing. The demands a professional (or amateur) athlete and worker may put on their limbs also factors in the manner in which the injury must be dealt with.

Fiberglass " playing casts " are used to get athletes back into their sport and workers return to their duties earlier before a injury has completely healed by giving extra stability and support for certain injuries. There are still injuries that a playing cast cannot be negotiated for since they require precision care.

Casting helps immobilize the bone but as the expense of the joint. Often once a cast is off significant stiffness is found in the adjacent joints to the fracture as well as muscle atrophy of the muscles controlling the joints.

Certain joints of the body should not be splinted for too long, as their stiffness may be very hard to treat. The hand for instance must be splinted in a specific way to prevent adhesions in the normal glide of the tendon. These soft tissue effects can be worse than the original fracture. For the most part soft tissue stiffness after appropriate casting is self limited or may be reversed with a course of rehabilitative stretches and exercises.

It is appropriate for each person to get the appropriate care for his or her injury. For example if someone had a small undisplaced fracture of their hand and decided they did well with only a splint and refused casting they would require many more weeks of an inferior form of immobilization to treat the same injury. These additive weeks of immobilization would also lead to a more profound soft tissue stiffness and possible malunion . It is therefore best to get the best possible care for each injury as soon as possible to eliminate these sad stories of malunions or early osteoarthritis.

Special Note

The purpose of this instructive workshop is to teach simple basics of wound protection. For definite diagnosis of injury examination with x-rays and review by a qualified physician is strongly advised. It would be very wrong to treat complicated fractures that require immediate surgery and reduction with simple splinting. These measures are taught as simple maneuvers to 'do no harm' while arranging transfer to a more advanced center, where the diagnosis can be made definitely.

Glossary of Terms

Closed Fracture - a fracture in a bone with skin intact.

Open (or compound fracture) - this fracture has open communication with the skin so bacteria have entered the wound. Their bacteria will multiply and cause rapid infection. All open fractures must be cleaned (by appropriate people) and referred to an orthopedic surgeon.

Oblique Fracture - a fracture on X-ray running less than 90 to the long axis of a bone.

Spiral Fracture - is caused by twisting (this is highly suggestive of child abuse)

Greenstick Fracture - is seen in children whose bones aren't as hard as adults. The bone is bent and fractured on the side where it is compressed.

Torus Fracture - caused by a compressive load on a bone (in children)

Comminuted Fracture - a fracture with two or more boney pieces.

Avulsion Fracture - a small chip of bone caused by excessive pull where a muscle inserts onto the bone.

Impacted Fracture - when bone is forcibly compressed, usually very stable

Stress Fracture - a boney overload where repetitive force has gradually caused the bone to crack under pressure.

Pathological Fracture - a fracture of a site where bone is weakened by some other disease. When suspected should suspect a tumor or osteoporosis.

Describing a Fracture (Usually with X-rays)

Communicating the status of a fracture and documenting changes is very helpful to orthopedic doctors when they are called upon for help.

Alignment describes the relationship of the fragments along the long axis of the bone, in degrees. It is not as accurate without X-rays but this can be also used to describe the apparent position of a deformity by a layperson.

Position of Fracture Surfaces

Using X-rays the displacement of the fracture surfaces are described either as partial 25-50-75% or complete.

Can also be described in on.

When using two view X-rays further counts on whether the displacement is anterior/posterior or medial/lateral .

Rotation - if the fragment appears rotated fracture healing is also described.

Union - the healing of a fracture. When clinical union has occurred there is a return to limb motion. X-ray changes may lag after clinical healing.

Problems with Healing

Mal-Union - this is when there is residual deformity after fracture has healed.

Delayed healing - is when healing takes longer than usual.

Non-Union - when the fracture ends to not unite and heal. A false joint appears between the 2 ends ( pseudo arthrosis ) this is not the same as healing by boney fibrous healing which is when boney fragments unite but are separated by fibrous connective tissue between that shows up as a black line.

Fracture Complications include arterial damage, nerve damage , compartment syndrome, infection, tenting of skin, accompanying soft tissue damage (crash injury)

Handling all orthopedic injuries with care and suspicion will help avoid problems with the above. Suspicious injuries must be periodically reexamined.

Delayed Complications

Reflex sympathetic dystrophy - a pain syndrome affecting the limb where blood circulation and nerve sensations are impaired after a fracture.

Osteomyelitis - a long-standing infection of bone.

Splinting

Best used for contusions that are severe and accompanied by swelling abrasions that cross-joints, tendon lacerations, and severe strains.

Specific Splints

Short arm sugar Tong splint (Resembles the sugar tong used for handling cubes of sugar)

•  Used for distal radius and ulna fractures or fractures of the wrist.

•  This splint limits flexion and extension of elbow and supination/formation at forearm yet still allowing for swelling (does not completely immobilize these joints)

•  Is used with an arm sling or shoulder immobilizer

Short arm volar splint (volar refers to support from the same side as the palm)

•  Used for wrist fracture or sprain

•  May be useful for severe tendonitis or carpal tunnel syndrome.

•  This is easy to apply. Patient can remove and reapply as needed

•  This doesn't control supination/promotion that well

Thumb Spica Splint

•  Useful when scaphoid fracture suspected or severe tendonitis of the thumb

Short Arm Ulna Gutter Splint

•  This is useful for boxers fractures of the 4 th or 5 th metacarpal

•  The special cure on this cast helps maintain a boxers fracture in reduction by 3 point contact

•  This cast should be applied by someone knowledgeable in treating boxers fracture

Long Leg Splint

•  Useful for stable distal femur fracture

•  Prevents flexion/extension of knee and ankle, and aversion/inversion at ankle

•  Very bulky and may break down and the splint may fracture at the knee or ankle. Usually the knee is flexed at 30 ° and ankle at 90 ° . (For knee fracture turn Achilles tendon)

•  Patients must remain non-weight bearing with this cast.

Short Leg Sugar Tong Splint

•  For medical and lateral malleoli fractures of the ankle

•  Limits ankle inversion/aversion and flexion inversion but not as well as a cast

•  Holds up reasonably on partial weight-bearing

Short Leg Posterior (Back slab) Splint

•  Is used for posterior lateral, on medial malleoli fractures and fractures of the foot, and selected stable other fractures

•  Also very useful for plantar fasciitis (This allows a continuous passive stretch of the plantar fascia and Achilles tendon at night and improves the flexibility

•  Be careful not to allow early breakdown of ankle portion of cast

•  Must be non-weight bearing as this is intended for nighttime use.

Proper Casts

Short Arm Casts

•  Useful for fractures of wrist and hand

•  When applied correctly allow extensive movement of elbows and fingers while immobilizing wrist

•  Allow some supination/promotion of forearm

•  (To eliminate this more effectively an above elbow cast is necessary to leave no supination/pronation freedom)

Thumb Spica Cast

•  Indicated for either confirmed or suspected scaphoid (navicular) fractures

•  Long arm version is often preferred for 1 st 2-8 weeks to allow for greater healing

•  Note- any pain after trauma in the anatomical snuffbox area of the wrist should be assumed to be a scophoid fracture

These scaphoid fractures are difficult to diagnose and if treated incorrectly can lead to malunion and arthritis. It is important to have all suspicious 'wrist sprains' reviewed by an orthopedic specialists to ensure this potential problem is never missed.

Short Leg Cast (non walking)

•  Indicated for malleoli fractures and non-displaced fibula fractures, and mid-foot fractures

•  This allows flexion and extension of the knee

•  Disadvantage is that it allows some rotation of lower leg below knee

Short Leg Walking Cast

•  Good for initial treatment and ankle sprains and hip fractures to ankle.

•  May be used as a follow-up cast for other leg fractures after several weeks in a new fit bearing cast

•  This allows easy mobilization after injury but patients should be selected

•  Inappropriate haste to use a walking cast or approved from a previous non-weight bearing situation may be detrimental

•  Disadvantages include heel breakdown since plaster cast is not commonly used for walking casts, this is less of a problem than previous

•  When the layers of the cast are applied cohesively (and laminate together properly) there is also less likelihood of breakdown

Short Arm Sugar Tong Splint

•  Elbow is position at 90 ° with neutral position of the wrist (no supination or pronation at the forearm)

•  Wrist is positioned slightly Dorsiflexed t 10 ° to attain a position of proper function

•  Measure length of splint using padding

•  For forearm, splint should go from just before the MCP joint on dorsal side, around the elbow and back to the distal palmer crease

•  Next measure several strips of material (plaster or fiberglass) equal to the length previously measured

•  One option is to place these measured strips inside a stockinet, then wet them (the additional use of the stockinet prevents a mess)

•  Padding should be placed between the limb and the splint

•  (I usually apply this on the patients arm but others may apply it to the cast)

•  Apply the splint

•  Have an assistant keep splint in place while you wrap roll on tensor wrap over top

•  The wrap will mold it comfortably to the elbow and wrist

•  After splint hardened, re-evaluate if initial wrap is too tight

•  At this stage you may replace the wrap with an ACE bandage

Ensure patient is educated on proper cast care and maintaining of injury.

Splint rolls have the padding integrated into the cast material and the roll is simply measured out and applied. Which makes this an easier one step procedure.

Thumb Spica Splint

Position forearm in neutral (no supination or pronation) with wrist slightly dorsiflexed (10-15 ° ) and thumb relaxed and extended (not the thumbs up position of hitchhikers)

Measure splint length. Should be two finger widths from anticubital fossa to half way down thumbnail.

Apply splint. Have assistant hold splint while you wrap with gauze roll or ACE bandage. Mold carefully around hand, thumb, and wrist. Evaluate fit of splint after hardened. Instruct patient on cast care and follow-up of injury.

Volar Splint

The forearm is placed in neutral (no supination or pronation) and wrist in 10-15 ° of dorsiflexion.

Measure the splint from 2 nd palmar crease to finger widths from the anticubital fossa.

Add padding to arm or on splint itself.

Apply splint and have assistant maintain position as you apply wrap. After splint hardened, review position and comfort. Educate patient on proper cast care.

Ulnar Gutter Splint

Position hand MCP flexed and at the wrist at 15 ° of dorsiflexion.

Measure from the tip of the finger to within 2 finger widths of the anticubital fossa. Apply padding. Apply splint, using an assistant to maintain position. Carefully review this splint as it is hardening since it is easy to lose position as the splint hardens. Explain this to the patient and it will help them maintain the position.

Review the hardened splint for position and comfort. Give each patient instruction on cast care.

Stir-up Splint (Sugar Tung) Of Lower Extremities

Position with ankle at 90 ° with no inversion/aversion of the foot. Have the person also flex their knee at 90 ° , as this will allow them to maintain 90 ° at the ankle.

Measure the splint length two fingers below the fibula head laterally down under the heel at up to the same height on the inside. Apply padding, then splint. Use an assistant to maintain position while wrap applied. Mold to splint with care about both malleoli and lower leg.

After splint hardened check position and comfort. Then give patient cast care instruction. Make sure they are proficient with crutches and do not weight bear on that leg.

Posterior Night Splint

Posterior slab applied to leg with knee flexed at 90 ° and foot in maximal dorsiflexed position at the ankle, and big toe.

Measure splint 3 finger lengths below fibular head to tip of big toe. Cut away material from where toes 3,4,5 would be, as this would make the splint more comfortable. Apply padding, then splint. Have assistant maintain position during wrap making sure that both big toe and ankle are maximally dorsiflexed. After wrap, mold splint around malleoli. Patient may use ACE wrap to apply cast with at home.

Applying Pre-Made Splints

•  Cut to exact length

•  Place in cool water and squeeze 3-4 times in water. Remove and squeeze to remove excess water

•  Placing on top of an absorbent towel will also remove water.

Note if you are using plantar and making your own back slabs, do not squeeze excessive water out too vigorously as this will lose some of the impregnated gypsum in the roll. Instead gently twist or squeeze the excess water out.

Common Casts

Short arm Cast

Position hand in neutral position with slight dorsiflexion at wrist.

Measure from the metacarpal heads to the anticubital fossa and cut stockinet to length, allowing for extra stockmitte to fold over at each end.

Put stockinet on and smooth any wrinkles.

Wrap padding; overlap approximately 50% of width.

Padding should extend from palmar crease to just before the anticubital fossa.

Give enough padding around thumb without pressing on web space.

Wet cast and apply in wrapping motion with moderate tension.

Overlap rolls by 50% of width.

Mold cast to support hand and wrist with slight dorsiflexion.

Fold stockmitte over cast ends to make a smooth edge.

Long Arm Cast

Position hand in neutral position with moderate dorsiflexion of wrist, elbow is flexed at 90 ° .

Measure stockmitte from metacarpal head to shoulder allowing for extra length to fold over cast edges later.

Cut small notch in stockinet for thumb.

Apply stockinet, smoothing out any wrinkles.

Wrap with cast padding overlapping 50%.

This should extend from the palmar crease of the hand to mid deltoid.

Wet and apply cast material to support hand and wrist, make sure wrist is still in moderate dorsiflexion.

Fold stockinet over edges to give smooth edges.

Thumb Spica Cast

Position the hand in neutral position with moderate dorsiflexion of wrist and thumb in dorsiflexion.

Measure stockinet from metacarpal head to anticubital fossa allowing for a little extra length to later fold over edges.

Cut hole in stockinet for thumb.

A small 1-inch stockinet can be used for the thumb.

Wrap padding over taping 50%.

Special care to the thumb should be made.

Ensure that there is adequate padding without pressing on web space.

Wet cast material and apply over-lapping 50%.

For the thumb smaller rolls can be used or you can pre-cut a regular sized roll before you start to allow finer application.

Mold cast to support hand and wrist with wrist still in moderate dorsiflexion.

Fold over stockinet to cover ends.

A final thin layer of casting material may be added to cast and reinforce strength.

Short Leg Cast

Position the ankle in neutral position (90 degrees)

Measure stockmitte from metatarsal head to knees, adding a little extra length to be folded over the cast later.

Slide stockinet on, smoothing wrinkles.

If a crease forms at the ankles, it can be trimmed away with scissors.

Wrap padding starting at foot overlapping 50%.

Padding should extend from metatarsal heads to just distal to fibular head.

Apply enough padding at heel, malleoli, metatarsal heads, and anterior tibia, as these are all boney prominences, which require added protection.

Wet and apply cast material.

Mold cast and ensure ankle is still in its original neutral position. (Often a patient will unconsciously shift during the wrapping stage)

Fold stockmitte over edges and apply final layer of material.

For walking cast apply overlapping, reinforcing strips at heel and foot with a plastic cast heel, prior to final layer.

Long Leg Cast

Position the ankle at neutral position (90 ° ) and knee at 20-30 ° flexion.

Measure from metatarsal heads to groin.

Cut stockinet with extra length to fold over on cast edges later.

Apply and smooth over stockinet to eliminate creases.

Apply padding starting at foot from the metatarsal heads and extending to just below groin.

Add sufficient padding to boney prominences, heel, malleoli, metatarsals heads, anterior tibia, and femoral condyles.

Apply padding overlapping 50%.

Apply cast material also overlapping 50%.

Mold cast material to ensure neutral position of ankle then around the femoral condyles of the knee.

Fold over stockinet edges to make smooth edges.

For walking casts use-overlapping reinforcing strips under the heel and foot (or plastic heel) then apply reinforcing layer to edges of stockinet exposed.