Cast Material Types PDF

Types of cast material Haythem zein M.D orthopedic Types of cast material PLASTER OF PARIS FIBERGLASS CAST ??? Plaster of Paris Plaster of Paris Plaster of Paris Plaster of Paris Size 7.5 cm?? 10 cm?? 15 cm?? 20 cm?? Fiberglass cast  Com...

Types of cast material Haythem zein M.D orthopedic Types of cast material PLASTER OF PARIS FIBERGLASS CAST ??? Plaster of Paris Plaster of Paris Plaster of Paris Plaster of Paris Size 7.5 cm?? 10 cm?? 15 cm?? 20 cm?? Fiberglass cast  Common size 2 3 4 5 inch Takes few min.to reach near full integrity and more resistant to deformation Than p.o.p. so molding with fiberglass is much more difficult Fibergl Water does not compromise a fiberglass ass It used for non displaced fracture cast Better to not use in acute stage except closed observation Difficult at.during.removal. Don’t harm 1. Elastic bandages such as an all cotton elastic (ACE) bandage should be applied loosely so that the elasticity can accommodate any future swelling. 2. Elbows, forearms, and the lower leg and foot have the highest risk of compartment syndrome after cast application. Use caution when applying a cast in the acute setting. 3. Because plaster can expand, it is better to use plaster rather than the more rigid fiberglass cast in the acute setting. 4. Plaster and fiberglass cure with an exothermic reaction; thus inadequate padding, lack of exposure to ambient air (under a blanket), or use of water that is above room temperature can result in thermal injuries, including second-degree burns.  What to Immobilize For intraarticular or periarticular fractures, the bone proximal and distal to the joint involved should be included (one above and one below). For extra-articular fractures, immobilize one joint above and one joint below Examples of correct immobilization: a. Wrist fracture (distal radius): Bone above = the radius; begin the cast/splint above the elbow to prevent forearm (radial) rotation at the wrist. Bone below = the carpals; end the cast/splint just proximal to the metacarpophalangeal joints (Figures 12-1 and 12-2). What Position to Immobilize b. Tibial shaft fracture: Joint above = the knee; begin the cast/splint as high up the leg as possible to limit knee motion. Joint below = the ankle; end the cast/splint just proximal to the toes to limit ankle motion. c. Ankle fracture (distal fibula/tibia): Bone above = the fibula + tibia; begin the cast/splint just distal to the knee joint. Bone below = the talus; end the cast/splint just proximal to the toes. What Position to Immobilize What Position to Immobilize What Position to Immobilize What Position to Immobilize What Position to Immobilize  Bivalving 1. If a cast is placed in the acute setting and edema is a concern, the cast can be split longitudinally along two sides (bivalving). 2. Splitting the cast material and the cast padding provides the most decompression. 3. For minimal edema, a single split can be performed (monovalving). 4. After the cast is split, overwrap it with either self-adhesive or elastic bandages. Wedging Wedging Wedging Wedging Wedges should be made out of plaster even if the cast is fiberglass. Rules of Wedging  SPLINT PRODUCTION BASICS Haythem Zein M.D orthopedic Padding 1. Application of cast padding: a. Begin with a circumferential wrap at one end. b. Progress to the other end while overlapping each layer by 50%. c. Return to the starting point while overlapping each layer by 50%. d. Avoid seams on the concave side of a joint: “span the fossa”. 2. Avoid wrinkles. Padding 3. Application of cast padding cuffs a. A two-ply cuff of cast padding is applied at the terminal portions of a cast. b. Typically, a piece of cast padding is folded onto itself: i. This technique creates a loose end and a folded end, with a small tear starting at the loose end to get around corners if necessary. ii. The folded end is always positioned toward the outside of the cast.  Plaster onlay splint. Types of Plaster prepadded splint. splint Fiberglass prepadded splint. Type of splint 1. Plaster onlay splint : a. The cast padding is applied to the limb, then the slab of plaster is laid onto the cast padding. b.Cast padding is then rolled over the plaster. c.This technique produces the best conforming and most versatile splint. Type of splint 1. Plaster prepadded splint : a.Instead of placing cast padding directly on the limb, a splint can be prepadded and applied as a unit. b.A plaster prepadded splint is best for coaptation splints. c. Commercial prepadded plaster splint material is available. d.Prepadded plaster splint material can be placed inside a stockinette for additional versatility. Type of splint 1. Fiberglass prepadded splint: a.A fiberglass prepadded splint is a strip of fiberglass inside cast padding material that can be cut to any desired length. b.Commercially made fiberglass prepadded splints are available in a variety of widths from 3 to 6 inches. We do not recommend use of this type of product Plaster Onlay Splint 1. Place two layers of cast padding to allow a 1- to 2-cm cuff of padding proximal and distal to the plaster 2. Measure out the correct length of splinting material. Keep in mind that plaster will shrink in water by approximately 5%. 3. Prepare 10 to 12 layers of splinting material of the measured length and adequate width. 4. Activate the plaster by placing it in tepid water. 5. Allow the plaster to soak until it is softened. Plaster Onlay Splint 6. Remove any excess moisture from the plaster. 7. Wring any air pockets or bubbles out of the plaster by running the strip between two fingers. 8. Apply the plaster slab to the limb. Plaster Prepadded 9. If the slab is too long, either fold it back or cut it to size. 10.Overwrap with cast padding. 11.Overwrap with an elastic or self- adherent bandage. Plaster Prepadded 1. Measure out the correct length of splinting material. Keep in mind that plaster will shrink in water by approximately 5%. 2. Prepare 10 to 12 layers of splinting material of the measured length and adequate width. 3. Roll out four layers of cast padding on a flat surface a few centimeters longer than and twice as wide as the slab of plaster. 4. Place a strip of cast padding twice the length of the plaster slab in the center of the cast padding. 5. Activate the plaster by placing it in tepid water. Plaster Prepadded 1. Allow the plaster to soak until it is softened. 2. Remove any excess moisture from the plaster. 3. Wring any air pockets or bubbles out of the plaster by running the strip between two fingers. Plaster Prepadded 4. Place the plaster slab in the center of the padding material. 5. Fold over the cast padding to cover the edges of the plaster slab. 6. Fold a double-length strip of padding to cover any exposed plaster. Plaster Prepadded 7. Place the splint into a stockinette for extra padding if desired. 8. Apply the prepadded splint to the limb. 9. If the splint material is too long, either fold it back or cut it to size. 10. Overwrap the splint with an elastic or self-adherent bandage. Fiberglass Prepadded Splint 1. Place two layers of cast padding to allow a 1- to 2-cm cuff of padding proximal and distal to the plaster. 2. Measure out the correct length of splinting material. 3. Cut the splint to size. 4. Ensure that no fiberglass is exposed at the cut ends. Fiberglass Prepadded Splint 5. Activate the fiberglass by placing it in tepid water. 6. Remove any excess moisture from the fiberglass. 7. Apply the prepadded splint to the limb. 8. If the splint material is too long, either fold it back or cut it to size. 9. Overwrap the splint with an elastic or self-adherent bandage. Thank you CAST PRODUCTION BASICS Haythem Zein M.D. Orthopedic  I. Plaster cast: Types of II. Fiberglass cast casts III. Elastic cast: I. Plaster cast 1. The strength of the cast depends on the removal of any air pockets from between each sheet of plaster..‫تعتمد قوة الجبيرة على إزالة أي جيوب هوائية من بين كل ورقة من الجبس‬ a. Use very wet plaster..‫سا مبلالً للغاية‬ ً ‫استخدم جب‬ b. Always roll the plaster on the cast. Do not lift the roll of plaster away from the cast; a “wall” of liquid plaster will form between the roll and the cast and help fill in air spaces. ‫ ال ترفع لفة الجبس بعيدًا عن الجبيرة؛ سيتشكل "جدار" من‬.‫دحرج الجبس دائ ًما على الجبيرة‬.‫الجبس السائل بين اللفافة والجبيرة ويساعد في ملء الفراغات الهوائية‬ c. Be sure to laminate (i.e., smooth plaster into any remaining air pockets) as you roll each layer of the cast. ‫تأكد من الترقق (أي وضع الجبس الناعم في أي جيوب هوائية متبقية) أثناء لف كل طبقة من‬.‫الجبيرة‬ I. Plaster cast d. A well-made cast needs to be only four to six layers thick..‫يجب أن يكون الجبس المصنوع جيدًا بسمك أربع إلى ست طبقات فقط‬ e. Look at your plaster on postreduction radiographs: the plaster should be one solid line with no onion-skinning appearance. ً ‫ يجب أن يكون الجبس خ‬:‫انظر إلى الجبس في صور األشعة السينية بعد التخفيض‬.‫طا واحدًا متماس ًكا بدون مظهر قشر البصل‬ f. A badly made cast will have uneven plaster thickness, show “onion skinning,” and appear fuzzy..‫ ويبدو زغبيًا‬،"‫ ويظهر "قشر البصل‬،‫سيكون الجبس المصنوع بشكل سيئ بسمك جبس غير متسا ٍو‬  I. Plaster cast 2. Advantages of a plaster cast: :‫مزايا الجبيرة الجبسية‬ a. A plaster cast will accommodate a small amount of edema..‫تستوعب الجبيرة الجبسية كمية صغيرة من الوذمة‬ a. A plaster cast is the best mode of immobilization to hold a fracture reduction..‫تعتبر الجبيرة الجبسية أفضل وسيلة للتثبيت لتثبيت الكسر‬ 3. Disadvantages of a plaster cast: :‫عيوب الجبيرة الجبسية‬ a. Even a well-made plaster cast will begin to crumble after 6 weeks and may need to be reinforced with a fiberglass outer shell..‫ أسابيع وقد تحتاج إلى تعزيزها بغالف خارجي من األلياف الزجاجية‬6 ‫حتى الجبيرة الجبسية المصنوعة جيدًا ستبدأ في االنهيار بعد‬ a. Creating a plaster cast is technically more demanding..‫إن صنع الجبيرة الجبسية يتطلب الكثير من الجهد من الناحية الفنية‬ b. c. Creating a plaster cast is messy ‫إن صنع الجبيرة الجبسية أمر فوضوي‬ II. Fiberglass cast: 1. Fiberglass should be rolled away from the skin..‫يجب لف األلياف الزجاجية بعيدًا عن الجلد‬ a. Avoid placing too much tension on the fiberglass..‫تجنب وضع الكثير من الضغط على األلياف الزجاجية‬ b. Be careful with any exposed edges on skin..‫حذرا مع أي حواف مكشوفة على الجلد‬ ً ‫كن‬ 2. Advantages of a fiberglass cast: :‫مزايا قالب األلياف الزجاجية‬ 3..‫يحتفظ قالب األلياف الزجاجية بسالمته البنيوية في الماء‬ a. A fiberglass cast will retain its structural integrity in water..‫يأتي قالب األلياف الزجاجية بألوان‬ b. A fiberglass cast comes in colors..‫قالب األلياف الزجاجية خفيف الوزن ولكنه قوي‬ c. A fiberglass cast is lightweight yet strong. d. A fiberglass cast is easier to apply than a plaster cast..‫قالب األلياف الزجاجية أسهل في التطبيق من قالب الجبس‬ :‫عيوب قالب األلياف الزجاجية‬ 4. Disadvantages of a fiberglass cast:.‫لن يتحمل قالب األلياف الزجاجية تقليل الكسر‬ a. A fiberglass cast will not hold a fracture reduction. b. A fiberglass cast will not expand to accommodate any swelling..‫لن يتمدد قالب األلياف الزجاجية الستيعاب أي تورم‬  III. Elastic cast 1. Elastic casting material should be rolled away from the skin..‫يجب لف مادة الصب المرنة بعيدًا عن الجلد‬.‫تجنب وضع الكثير من التوتر على المادة المرنة‬ a. Avoid placing too much tension on the elastic material..‫حذرا مع أي حواف مكشوفة على الجلد‬ً ‫كن‬ b. Be careful with any exposed edges on skin. 2. Advantages of elastic casting material: a. Elastic casting material will retain its structural integrity in water. :‫مزايا مادة الصب المرنة‬ b. Elastic casting material is lightweight..‫ستحتفظ مادة الصب المرنة بسالمتها البنيوية في الماء‬ c. Elastic casting material allows some motion..‫مادة الصب المرنة خفيفة الوزن‬ d. Elastic casting material is easier to apply than a plaster cast..‫تسمح مادة الصب المرنة ببعض الحركة‬.‫مادة الصب المرنة أسهل في التطبيق من الجبس‬ 3. Disadvantages of elastic casting material: a. Elastic casting material will not hold a fracture reduction. b. Elastic casting material will not expand to accommodate any swelling. :‫عيوب مادة الصب المرنة‬ c. Elastic casting material allows some motion..‫لن تتحمل مادة الصب المرنة تقليل الكسر‬.‫لن تتمدد مادة الصب المرنة الستيعاب أي تورم‬.‫تسمح مادة الصب المرنة ببعض الحركة‬  Plaster Cast 1. Cut two pieces of stockinette, one for the proximal end and one for the distal end..‫ واحدة للطرف القريب واألخرى للطرف البعيد‬،‫اقطع قطعتين من القماش القطني‬ 2. Place the stockinette onto the limb ‫ضع القماش القطني على الطرف‬ 3. Place two layers of cast padding to allow a 1- to 2-cm cuff of padding proximal and distal to the plaster..‫ سم في الطرف القريب والطرف البعيد للجص‬2 ‫ إلى‬1 ‫ضع طبقتين من الحشوة الجبسية للسماح بطبقة من الحشوة بسمك‬ 4. Fold back the stockinette to create a neat edge ‫اط ِو القماش القطني للخلف إلنشاء حافة أنيقة‬ 5. Activate the plaster by placing it in tepid water..‫قم بتنشيط الجص بوضعه في ماء فاتر‬  Plaster Cast 6. Allow the plaster to soak until it is softened..‫اترك الجص منقو ًعا حتى يلين‬ 7. Do not wring out the plaster: keep it sloppy wet..ً‫ حافظ على بقائه مبلال‬:‫ال تعصر الجص‬ 8. Apply the plaster to the limb..‫ضع الجص على الطرف‬ a. Begin with a circumferential wrap at one end..‫ابدأ بلفافة محيطية عند أحد الطرفين‬ a. Progress to the other end while overlapping each layer by 50%..%50 ‫انتقل إلى الطرف اآلخر مع تداخل كل طبقة بنسبة‬ b. Return to the starting point while overlapping each layer by 50%..%50 ‫عد إلى نقطة البداية مع تداخل كل طبقة بنسبة‬ c. Avoid seams on the concave side of a joint: “span the fossa”.."‫ "امتد عبر الحفرة‬:‫تجنب اللحامات على الجانب المقعر من المفصل‬  Plaster Cast 9. If the plaster encroaches on the cuff of the cast padding or is in contact with the skin, wait until it has cured (5 to 10 minutes) and then trim it with a cast saw. 10. Tips and tricks: a. Around elbows, knees, and ankles, apply a four-layer plaster slab to the convex side of the joint to minimize bulk on the concave side. b. Roll four times around either end of the cast to ensure that both ends are rigid. c. To laminate the cast as you go, smooth out the plaster with the hand not holding the plaster roll. i. While pulling the roll of plaster toward you with your right hand, the left hand should mirror that motion while pressing the heel of your hand against the cast. ii. While pushing the roll of plaster away from you with your left hand, the right hand should mirror that motion while pressing the heel of your hand against the cast.  Plaster Cast d. To get around the thumb-index web space, either twist the roll 360 degrees or pinch the sheet of plaster.  Plaster cast e. To make a turn: i. Lift the plaster away from the limb. ii. Pinch one end of the strip. iii. Angle the plaster and begin the roll. iv. Smooth out (laminate) the dog ear.  Plaster cast f. When the roll of plaster begins to unravel, it is called a “banana.” i. If a banana occurs, push the plaster back in and pinch the end closed. ii. If a banana cannot be fixed, cut off the roll and begin a new roll.  Fiberglass/Elastic Cast 1. Cut two pieces of stockinette, one for the proximal end and one for the distal end. 2. Place the stockinette onto the arm. 3. Place two layers of cast padding to allow a 1- to 2-cm cuff of padding proximal and distal to the cast material. 4. Fold back the stockinette to create a neat edge. 5. Activate the cast material by placing it in tepid water. 6. Remove any excess moisture from the casting material.  Fiberglass/Elastic Cast 7. Apply the casting material to the limb. a. Begin with a circumferential wrap at one end. b. Progress to the other end while overlapping each layer by 50%. c. Return to the starting point while overlapping each layer by 50%. d. Avoid seams on the concave side of a joint: “span the fossa”. e. The casting material can be cut with trauma shears to facilitate turns and passage through web spaces.  Fiberglass/Elastic Cast 8. If the casting material encroaches on the cuff of the cast padding or is in contact with the skin, wait until it has cured (5 to 10 minutes) and then trim it with a cast saw. 9. Tips and tricks: a. Around elbows, knees, and ankles, shuffle the casting material back and forth over the convex side of the joint to minimize bulk on the concave side. b. Roll four times around either end of the cast to ensure that both ends are rigid.  COMMON ERRORS 1. Padding is inappropriate: a. Too little padding can lead to pressure necrosis and saw burns. b. Too much padding can result in inadequate immobilization and does not accommodate swelling. c. Wrinkled padding can cause pressure necrosis. 2. Activating plaster in hot water: a. Casting material often is activated in hot water to reduce the amount of time needed for the cast to harden. b. The faster casting material sets, the more heat is produced. c. Heat produced by fast-setting casting material places the patient at risk for thermal injury.  COMMON ERRORS 3. Cast material thickness too thick: a. The more material that is used, the larger the exothermic reaction and the greater the risk of thermal injury. 4. Failure to allow the splint or cast to fully harden: a. A busy clinician may leave a recently applied splint or cast on a pillow or on a stretcher. b. Static pressure from the pillow or stretcher can increase the temperature at that pressure point, leading to thermal injury. c. Any molding may be lost if the casting material has not hardened. This consequence most commonly occurs when applying a splint or cast around the ankle; as a result, the foot falls into equinus. 5. The cast is wrapped too tightly: a. COMPARTMENT SYNDROME!  COMMON ERRORS 6. The cast or splint is applied unevenly: a. The tendency exists to apply more of the splint around the apex of the injury. b. An unevenly applied cast or splint is most commonly detected on postapplication radiographs. 7. The cast or splint is not laminated: a. Lack of lamination results in a weak splint or cast. b. Lack of lamination is most commonly detected on postapplication radiographs as an onion-skinning appearance. The plaster should be one solid line.  COMMON ERRORS 8. The wrong joints are immobilized or the joints are immobilized in the wrong position: a. Immobilizing more joints than is necessary can result in permanent iatrogenic loss of joint motion. b. Immobilization of fewer joints than is necessary can result in fracture displacement, neurovascular injury, and unnecessary pain and suffering. c. Immobilization in an incorrect position can result in both fracture displacement and iatrogenic loss of joint motion. 9. The cast saw is used in an inappropriate fashion: a. The cast saw should never be dragged along a cast. Upper Extremity Splints and Cast - Haythem zein  FIGURE-OF-8 SPLINT 1. Figure-of-8 splints are used primarily for fractures about the clavicle. 2. Figure-of-8 splints are commercially prepared devices intended to create a reduction force on the clavicle 3. No difference in outcome is seen between a figure-of-8 splint and a sling for closed management of clavicle fractures.  indication 1. Minimally displaced clavicle shaft fractures 2. Medial physeal clavicle fracture  pearls 1. Reduction is not required for most clavicle fractures. 2. Clavicle fractures with more than 1.5 cm of overlap result in long-term disability and should be treated with an open reduction and internal fixation. 3. Fractures that tent the skin can erode through the skin and are unlikely to heal without open reduction and internal fixation.  Basic Technique 1. Patient positioning: a. Standing 2. Landmarks: a. Clavicle b. Acromioclavicular joint 3. Steps: a. Have the patient stand. b. Fit the patient with a figure-of-8 splint. c. The figure-of-8 splint should be placed so that the center of the “8” rests on upper back.  Detailed Technique 1. Have the patient stand. 2. Apply the figure-of-8 splint so that the center of the “8” comes to rest between the shoulder blades on the upper back. 3. Adjust the figure-of-8 dressing so that it is as tight as possible while still being comfortable to wear  ARM SLING/ARM SLING AND SWATH 1. s1.The arm sling is used for a variety of condition 2. A swath wrapped around the body is added for shoulder immobilization  Indications for Use 1. Sling: a. Clavicle fractures b. Minimally displaced proximal humerus fractures c. Acromioclavicular separations d. Support for splints and casts of the upper extremity 2. Sling and swath: moderately displaced proximal humerus fractures  Precautions 1. Ensure a proper fit to prevent pressure complications at the back of the neck. It is recommended that a well-padded sling be used or that the neck be padded with cast padding and/or an Army Battle Dressing 2. Elderly patients and patients with compromised skin (such as persons taking steroids on a long-term basis) should be monitored closely for skin breakdown  Pearls 1. The adult elbow does not tolerate immobilization well. If possible given the nature of the injury, the patient should be instructed to perform daily elbow, wrist, and hand range-of- motion exercises. 2. If a reduction maneuver has been performed, obtain postreduction radiographs while the patient is wearing the sling or the sling and swath to ensure maintenance of the reduction.  sling a. Have the patient stand. b. Pad the neck strap of the sling to prevent pressure complications at the back of the neck c. Apply the sling and adjust the straps. d. Adjust the sling so it is tight enough to support the weight of the arm  2. Sling and swath: a. Have the patient stand b. Pad the neck strap of the sling to prevent pressure complications at the back of the neck. c. Place talcum powder on the ABD pad and fold the pad in half, with the talcum side facing out. d. Place the folded ABD pad in the axilla to absorb perspiration. e. Apply the sling and adjust the straps so it is loose while providing some support for the weight of the arm. f. Buckle and adjust the circumferential body strap. g. If using a sling only, swath the arm to the body using cast padding followed by application of a large elastic bandage Upper Extremity Splints and Casts 3 Haythem zein  COAPTATION SPLINT Pearls The key to applying a coaptation splint properly is to ensure that the splint always comes above the arm onto the shoulder  PearlS When applying the splint, have the patient turn his or her head to the contralateral side, which prevents the neck from pushing down the splint during application.  Pearls We prefer using a self-adhesive bandage to overwrap the plaster because it acts predictably during application, stays in place well, and looks better than other options.  Equipment 1. Stockinette: 4 inches wide, 6 feet long 2. Cast padding: 4 inches wide 3. Plaster: 4 inches wide 4. Elastic or self-adherent bandage: 4 inches wide 5. Silk tape: 2 inches wide (optional) 6. Bucket of tepid water  Basic Technique 1. Patient positioning: a. If possible, have the patient stand or sit up with his or her back off the stretcher. b. The elbow is placed at 90 degrees. c. If the patient is unable to sit up, move the head of bed as upright as possible.  2. Where to start: a. As high the axilla as possible b. If the fracture is in the proximal third of the humeral diaphysis (right at the level of the axilla on the lower radiograph), start the splint  3. Where to finish: At the base of the neck  4. Where to mold: Lateral aspect, distal to the fracture site  Steps: a. Measure the length of the splint using plaster b. Roll out the cast padding. c. Roll out the plaster. d. Cut a 6-foot length of 4-inch stockinette. e. Position the patient. f. Prepare the plaster in the usual fashion. g. Place a splint inside a stockinette. h. Apply the splint. i. Definitively secure the splint with an elastic bandage. j. Complete the stockinette.  Detailed Technique 1. Measure the length of the splint. a. Use the contralateral side. b. Hold one hand in the axilla and wrap the plaster around the elbow until the base of the neck is reache c. Mark the length on the plaster by making a small tear on one side.  Detailed Technique 2. Roll out the plaster a. The plaster slab should be 10 to 12 sheets thick. b. Use the measured length.  3. Roll out the cast padding. a. Use the usual technique that will allow the cast padding to be folded b. Add at least 6 inches of length so the splint may be folded over.  Detailed Technique Cut a 6-foot length of 4-inch stockinette.  Detailed Technique Position the patient a. Have the patient sit upright if possible. b. Place the patient's elbow at 90 degrees. c. Ensure that the patient's head is facing toward the contralateral side.  Detailed Technique 8. Apply the splint a. Start in the axilla or at an appropriate starting point given the fracture site. Provisionally secure it with cast padding at the middle arm.  Detailed Technique b. Loop the splint around the elbow. Again, provisionally secure it with cast padding at the middle arm c. Momentarily fold the remaining part of the splint down. d. Pass the loose end of the stockinette around the neck.  Detailed Technique Apply the mold. Most fractures require a two- point mold, with one hand anterolateral at the fracture site and the other posteromedial at the elbow  Place a cast padding wedge under the arm to counteract varus displacement of the fracture (optional)  A posterior slab may be added to control elbow motion for more distal fracture Upper Extremity Splints and Casts By haythem Zein M.D orthopedic  Three main topics POSTERIOR LONG ARM SUGAR-TONG ELBOW SPLINT CAST SPLINT First Topic POSTERIOR ELBOW SPLINT  POSTERIOR ELBOW SPLINT I. Overview 1. A posterior elbow splint is inherently weak. Struts must be added to prevent elbow extension in the splint. 2. Two techniques are described for stabilization of the posterior elbow splint: a. External struts with tape b. Internal struts with plaster II. Indications for Use 1. Fractures about the elbow 2. Postoperative/postinjury elbow immobilization 3. Elbow dislocations  POSTERIOR ELBOW SPLINT III. Precautions 1. The wrist is usually immobilized to control for pronation and supination about the elbow. Elbow dislocations should be splinted in at least 90 degrees of flexion with the wrist in pronation. 2. Ensure that the splint remains proximal to the palmar flexion crease to preserve complete finger range of motion. 3. At the antecubital fossa, do not allow edges of cast padding to lay immediately within the fossa borders. a. Allowing edges of cast padding to lay immediately within the fossa borders will create wrinkling and can lead to skin breakdown in this very fragile area. b. Span the fossa by having the mid point of the cast padding roll directly over the elbow flexion crease. c. By having the mid point of the cast padding roll directly over the elbow flexion crease, the cast padding will be slightly tented above the fossa and will not be in direct contact, thus reducing the risk of skin breakdown. 4. Because the olecranon and ulnar styloid are at risk in this splint, care should be taken to apply additional padding over these areas.  POSTERIOR ELBOW SPLINT IV. Pearls 1. A posterior elbow slab is very weak and does not provide significant immobilization. a. Some form of strut must be made to prevent flexion/extension. b. The struts can be internal to the splint or external to the splint: 1) Internal struts are made of plaster and applied directly to the posterior slab, providing resistance to both flexion and extension. 2) External struts are made of tape and applied to the splint after it is definitively secured, providing resistance to extension but not flexion. 2. Have the patient or an assistant hold the hand of the affected side by the fingertips to help with positioning and reduce pain. V. Equipment 1. Cast padding: 3 inches wide 2. Plaster: 4 inches wide and 2 inches wide 3. Elastic or self-adherent bandage: 4 inches wide 4. Bucket of tepid water 5. Tape (optional): 2 inchesBasic POSTERIOR ELBOW SPLINT VI. Technique 1. Patient positioning: a. The patient should sit upright with his or her shoulder off the side of the bed. b. The elbow should be in the desired position of flexion and pronation/ supination. 2. Where to start: a. Proximal to the palmar flexion crease 3. Where to finish: a. Immediately distal to the axillary fold of the arm 4. Where to mold: a. Slight supracondylar mold above the elbow  POSTERIOR ELBOW SPLINT VII. Detailed Technique 1. Measure the length of the splint using plaster. a. Use the contralateral side. b. Start proximal to the palmar flexion crease. c. End immediately below the axillary fold. 2. Roll out the plaster. a. The posterior slab should be 10 to 12 layers thick and 4 inches wide. b. Side struts can be 8 to 10 layers thick and 2 inches wide. 3. Position the patient: a. Standing or sitting upright b. Arm freely off to the side c. Elbow bent to desired degree of flexion POSTERIOR ELBOW SPLINT 4. Wrap the extremity in cast padding. a. Start at either end. b. Circumferentially wrap with cast padding, using a standard 50% overlap technique (see Chapter 12). Two layers of wrapping are sufficient. c. Carefully tear the cast padding so it conforms around the thumb interspace. Do not go past the palmar flexion crease. d. Span the fossa with cast padding at the antebrachial fossa. e. Tear several small strips of cast padding and apply them over the bony prominences of the olecranon and ulnar styloid to provide additional padding. POSTERIOR ELBOW SPLINT 5. Create three cast padding cuffs (see Chapter 12): a. Palmar flexion crease/metacarpal heads: This cuff should form a “V” at the ulnar aspect of the hand to allow for the cascade of the digits. a. Thumb: This cuff should form a “V” at the base of the thumb. b. Proximal forearm: This cuff can be circular. POSTERIOR ELBOW SPLINT 6. Prepare the plaster. Use the usual technique of wetting and laminating (see Chapter 12). 7. Apply the plaster. a. Apply the posterior slab first. 1) Position the posterior slab over the ulnar border of the forearm, around the olecranon and the posterior aspect of the arm. 2) Provisionally secure with cast padding at the wrist, forearm, and arm if necessary. b. Apply side struts (if not using external struts). 1) Start laterally at the mid arm and angle obliquely toward the forearm. Laminate the side strut to the posterior slab. 2) Apply the medial side strut in the same position if additional stability is needed. Laminate the side strut to the posterior slab. POSTERIOR ELBOW SPLINT 8. Cover the plaster. Wrap cast padding over the top of the plaster to prevent adhesion of the plaster to the elastic or self-adherent bandage. 9. Definitively secure the splint with an elastic or self- adherent bandage. 10. Apply molding if necessary  POSTERIOR ELBOW SPLINT 11. Create an external strut (if no internal struts are used) after the plaster has set. Use the figure-of-8 technique with tape. a. Take 2-inch silk tape and begin at the mid point of the posterior aspect of the arm. b. Wrap around to the mid point of the anterior aspect of the arm. c. Span the fossa obliquely. d. Attach tape to the opposite aspect of the forearm. e. Wrap around the dorsal forearm. f. Span the fossa obliquely. g. Attach tape to the lateral aspect of the arm. h. At the intersection of the figure of 8, wrap with tape. Second Topic LONG ARM CAST  LONG ARM CAST I. Indications for Use 1. Pediatric supracondylar humerus fractures 2. Pediatric forearm fractures 3. Pediatric unstable distal radius fractures 4. Adult distal radius fractures 5. Adult forearm fractures LONG ARM CAST II. Precautions 1. Do not plaster over the thenar eminence. 2. Do not extend the plaster beyond the palmar crease. The patient must be able to flex his or her metacarpophalangeal (MCP) joints to at least 70 degrees. 3. At the antecubital fossa, do not allow edges of cast padding to lay immediately within the fossa borders. a. Allowing edges of cast padding to lay immediately within the fossa borders will create wrinkling and can lead to skin breakdown in this very fragile area. b. Span the fossa by having the mid point of the cast padding roll directly over the elbow flexion crease. c. By having the mid point of the cast padding roll directly over the elbow flexion crease, the cast padding will be slightly tented above the fossa and will not be in direct contact, thus reducing the risk of skin breakdown. 4. Because the olecranon and ulnar styloid are at risk in this splint, care should be taken to apply additional padding over these areas. 5. Be prepared to bivalve the cast to prevent compartment syndrome if postreduction swelling occurs. 6. Never cast an acute supracondylar fracture or floating elbow injury without bivalving. LONG III. Pearls ARM CAST 1. The easiest method is to create a short arm cast and then continue with the long arm portion. 2. Once you start “slinging” plaster more quickly, a long arm cast can be attempted in one step. 3. The easiest place to begin is at the wrist. The natural contour of the arm will prevent sliding. 4. It is difficult to control elbow flexion and forearm pronation when placing a long arm cast, especially in a child. a.To partially alleviate this difficulty, it is useful to have older children pretend they are a “drama queen” and have them place the dorsal aspect of their hand on their forehead after the short arm cast has been applied b.Once the patient is in this position, the long arm portion of the cast can be completed. c.Parents can aid with keeping the arm at 90 degrees of elbow flexion for younger children. III. Equipment 1.Stockinette: 3 to 4 inches 2.Cast padding: 3 to 4 inches 3.Plaster: 4 inches 4.Elastic or self-adherent bandage: 3 to 4 inches LONG ARM CAST V. Basic Technique 1. Patient positioning: a. Supine: 1) Have thin patients move their body all the way to the contralateral side of the stretcher. 2) The patient can then rest his or her elbow on the stretcher. b. Upright: Use a bedside table to allow the patient to place his or her arm at a comfortable level if no reduction is required. c. The elbow should be bent to 90 degrees with the arm upright. d. The wrist position depends on the type of fracture and the location of the fracture. 1) Distal radius fracture: a) Wrist in pronation 2) Fracture of both bones of the forearm: a) Proximal third: wrist in supination b) Middle third: wrist in neutral c) Distal third: wrist in pronation LONG ARM CAST 2. Where to start: a. Palmar flexion crease 3. Where to finish: a. Upper arm, below the axillary fold 4. Where to mold: a. Dependent on fracture 1) Distal radius fracture: a) Same as sugar tong 2) Fracture of both bones of the forearm: a) Interosseous mold b) Ulnar-sided flat mold LONG ARM CAST 5. Steps: a. Prepare the stockinette. b. Position the stockinette. c. Wrap the extremity in cast padding. d. Create three cast padding cuffs. e. Fold the stockinette over proximally and distally. f. Prepare the plaster roll in the usual fashion. g. Apply the plaster roll for a short arm cast. h. Reposition the patient. i. Apply the plaster roll to the elbow and arm. j. Split the cast, if necessary. LONG ARM CAST Detailed Technique 1. Prepare the stockinette by cutting it into two pieces: a. One piece for the proximal portion at the arm b. One piece for the distal portion at the hand 2. Position the stockinette: a. Place one stockinette over the upper arm. b. Cut a thumb hole in the mid portion of the other stockinette and fit this piece over the hand. c. The stockinette should extend to the proximal interphalangeal (PIP) joints.  LONG ARM CAST 3. Wrap the extremity in cast padding. a. Start at the wrist and circumferentially wrap distally. 1) Use a standard 50% overlap technique. 2) Two layers of padding are sufficient. b. Carefully tear the cast padding so as to conform around the thumb interspace. Do not go past the palmar flexion crease. c. Once the hand has been adequately padded, continue wrapping proximally to the proximal forearm. d. Span the fossa with cast padding at the antebrachial fossa. e. Continue proximally to area just below axillary fold. LONG ARM CAST 4. Create three cast padding cuffs. a. Palmar flexion crease/metacarpal heads: This cuff should form a “V” at the ulnar aspect of the hand to allow for the cascade of the digits. b. Thumb: Again, form a “V” at the base of the thumb. c. Proximal arm : This cuff can be circular. 5. Fold the stockinette over proximally and distally. Ensure that MCP motion is completely preserved. 6. Prepare the plaster roll in the usual fashion. LONG ARM CAST 7. Apply the plaster roll for a short arm cast. a. Start at the wrist and work distally. b. Use a twisting or pinching motion to get through the thumb interspace. Twist the plaster roll 360 degrees in the interspace. c. Roll two more times around the hand and through the thumb interspace. d. Continue the plaster proximally. Use the standard technique of laminating while rolling. e. Ensure that at least 3 to 5 layers of plaster are applied.  LONG ARM CAST 8. Reposition the patient if using the “drama queen” technique. a. The patient should be supine. b. The hand is on the forehead with the elbow flexed to 90 degrees. 9. 9. Apply a plaster roll to the elbow and arm. Be vigilant about avoiding patient movement when applying this portion of the cast. 10. Apply a mold, if desired. For a fracture of both bones of the forearm: a. An interosseous mold should be made over the forearm by compressing the anterior and posterior surfaces to make the cast more oval and less cylindrical.  LONG ARM CAST a. A straight ulnar border also is applied to prevent the fracture from falling to varus. 1) A straight ulnar border can be applied at the same time as the interosseous mold. 2) 2) Alternatively, after applying an interosseous mold, place the ulnar side of the cast on a hard flat surface to make sure it is flat. b. c. A supracondylar humerus mold also can be applied if desired. 11. Split the cast if necessary. Third Topic SUGAR-TONG SPLINT  SUGAR-TONG SPLINT I. Indications for Use 1. Distal radius fractures II. Precautions 1. It is crucial that the splint be neither too long nor too short. a. If the splint is too long and extends beyond the metacarpal heads, finger flexion is significantly impaired and permanent finger stiffness or contractures may ensue. b. If the splint is too short, the reduction will not hold. 2. Do not immobilize the thumb. This error is extremely common. Remember, the thumb must be able to oppose and thus, unlike the fingers, its range of motion begins at the basal joint (carpometacarpal joint). 1. Do not mold the splint in such a fashion that the wrist is flexed beyond 10 to 15 degrees; otherwise acute carpal tunnel syndrome may occur! SUGAR-TONG SPLINT III. Pearls 1. The normal cascade of the fingers slopes downward from the index to the little finger. a. A 30-degree cut can be made in one end of the plaster slab to incorporate this cascade. b. A curvilinear cut can be). made to free the thenar eminence about the thumb. 2. Before measuring the splint, it may be useful to perform a hematoma block, thus allowing the block to become effective while the splint is being measured. 3. It is better to measure the splint long rather than short. The splint can always be trimmed or folded over during application if it is too long, but a new splint will need to be made if it is too short. 4. The cast padding may be measured 1 to 2 inches long on the volar aspect so that it may be folded over the end of the plaster splint, thus providing a comfortable and safe edge to the splint. SUGAR-TONG SPLINT 5. The sugar-tong splint has a tendency to become very bulky at the elbow. a. To prevent bulkiness at the elbow, a small cut is made in the plaster at the elbow once it has been applied and provisionally fixed. b. The free ends are folded over one another to conform to the curvature of the flexed elbow.  SUGAR-TONG SPLINT IV. Equipment 1. Stockinette: 3 inches 2. Cast padding: 3 to 4 inches 3. Plaster: 3 to 4 inches 4. Elastic or self-adherent bandage: 3 to 4 inches 5. Portable radiograph machine (optional) V. Basic Technique 1. Patient positioning: a. The patient is either supine on the stretcher with the entire shoulder girdle off the side or the patient is sitting or standing. b. The elbow is bent at 90 degrees. c. The splint may be applied while the patient is in traction (see Chapter 10). 2. Where to start: a. Volar (palmar) aspect, immediately below the palmar crease 3. Where to finish: a. Dorsal aspect, immediately below the metacarpal heads SUGAR-TONG SPLINT 4. Where to mold (3-point mold): a. For a dorsally angulated distal radius fracture: 1) Dorsal aspect of the carpus 2) Volar forearm immediately proximal to the wrist crease 3) Dorsal aspect of the forearm 1) For a volarly angulated distal radius fracture: 1) Volar aspect of the carpus 2) Dorsal forearm immediately proximal to the wrist crease 3) Volar aspect of the forearm SUGAR-TONG SPLINT 5. Steps: a. Measure the length of the splint using plaster. b. Roll out the plaster. c. Roll out the cast padding. d. Position the patient. e. Set traction, if necessary. f. Obtain traction views, if necessary. g. Perform a reduction maneuver, if necessary. h. Prepare plaster in the usual fashion. i. Apply a splint. j. Definitively secure the splint with an elastic bandage. k. Perform a three-point mold. VI. Detailed Technique 1. Measure the length of the splint using plaster. a. Use the contralateral side. b. Start the volar (palmar) aspect at the palmar flexion crease. c. Wrap around the elbow and finish at the metacarpal heads. 2. Roll out the plaster. The plaster slab should be 10 sheets thick. 3. Roll out the cast padding. Use the usual technique that will allow the padding to be folded over. 4. Position the patient: a. The patient should be supine on the stretcher with the shoulder girdle entirely off the side. b. Prepare finger traps if using traction. c. Abduct the shoulder to 90 degrees and flex the elbow to 90 degrees to create a 90-90 position. SUGAR-TONG SPLINT 5. Set traction, if necessary. 6. Obtain traction views, if necessary (this step may be performed following the reduction maneuver, as desired). 7. Perform a reduction maneuver, if necessary. 8. Prepare plaster in the usual fashion, with wetting and laminating, followed by placement in cast padding.  SUGAR-TONG SPLINT 9. Apply a splint. a. Begin at the volar aspect. Do not go past the palmar crease. b. Wrap the splint around the elbow. c. Provisionally secure the splint at the wrist with cast padding. d. Ensure that the edges of the splint are at the correct length. 1) If the edges are too long, fold them over. 2) If the edges are too short, the splint will need to be remade. e. Cut a slit in the splint at the elbow to prevent bulk. Fold the edges over one another. SUGAR-TONG SPLINT 10. Definitively secure the splint with elastic or a self-adherent bandage. a. Start at the elbow. b. Ensure that the elastic or self-adherent bandage has only minimal contact with the skin. c. Wrap the elastic or self-adherent bandage distally. A hole can be cut out for the thumb, if desired (Figure 13-65). d. Secure the end with silk tape if needed (Figure 13-66). 11. Perform a three-point mold, if desired. Upper Extremity Splints and Casts Haythem zein M.D. orthopedic  Three Main Topics THUMB SPICA SPLINT SHORT ARM CAST THUMB SPICA CAST ULNAR GUTTER SPLINT  First Topic THUMB SPICA SPLINT  THUMB SPICA SPLINT I. Indications for Use 1. Scaphoid fractures 2. Thumb metacarpal fractures 3. Thumb carpometacarpal dislocations Precautions Be careful not to create a mold that is too dramatic, because the indentation in the plaster can lead to skin necrosis and pressure sores. II. Pearls 1. The application of cast padding is the most important aspect of this splint. 2. Careful attention should be paid to the area around the thumb to avoid bunching and wrinkles. III. Equipment 1. Stockinette: 3 inches 2. Cast padding: 3 inches 3. Plaster: 4 inches 4. Elastic or self-adherent bandage: 3 inchesBasic  THUMB SPICA SPLINT IV. Technique 1. Patient positioning: a. The elbow is bent to 90 degrees with the arm upright. b. Supine: 1) Have patients who are thin move their body all the way to the contralateral side of the stretcher. 2) The patient can then rest his or her elbow on the stretcher. c. Upright: 1) Use a bedside table to allow the patient to place his or her arm at a comfortable level. 2. Where to start: a. Distal to the thumb interphalangeal (IP) joint for thumb fractures b. Just proximal to the IP joint for scaphoid fractures 3. Where to finish: a. Mid to proximal forearm 4. Where to mold: a. The thumb should be abducted 30 degrees away from the hand, in its neutral position.  THUMB SPICA SPLINT 5. Steps: a. Measure the length of the splint using plaster. b. Roll out the plaster. c. Wrap the extremity in cast padding. d. Create three cast padding cuffs. e. Prepare the plaster. f. Apply the plaster. g. Cover the plaster. h. Definitively secure the splint with an elastic or self-adherent bandage.  THUMB SPICA SPLINT VI. Detailed Technique 1. Measure the length of the splint using plaster. Start at the thumb and go to the mid to proximal forearm. 2. Roll out the plaster. The plaster slab should be 10 sheets thick. 3. Wrap the extremity in cast padding a. a. Start at the wrist and circumferentially wrap distally to the hand. b. Use a standard 50% overlap technique Two layers of wrapping are sufficient. c. Carefully tear the cast padding so as to conform around the thumb interspace. Do not go past the palmar flexion crease. d. Once the hand has been adequately padded, continue wrapping proximally to the mid forearm  THUMB SPICA SPLINT 4. Create three cast padding cuffs: a. Palmar flexion crease/metacarpal heads: The cuff should form a “V” at the ulnar aspect of the hand to allow for the cascade of the digits. b. Thumb: Padding cuff at the tip of the thumb. c. Proximal forearm: This cuff can be circular. 5. Prepare the plaster. Employ the usual technique of wetting and laminating.  THUMB SPICA SPLINT 6. Apply the plaster: a. Position the plaster on the radial border of the thumb and forearm. b. Provisionally secure the plaster at the wrist with cast padding. 7. Cover the plaster. Place strips of cast padding over the top of the plaster to protect the elastic bandage. 8. Definitively secure the plaster with an elastic bandage: a. Begin at the thumb and work distally. b. An opening for the thumb web space can be cut into the elastic or self-adherent bandage. c. Work distally to the mid forearm. d. Secure the end with silk tape.  Second topic SHORT ARM CAST  SHORT ARM CAST I. Indications for Use 1. Distal radius fracture (nonacute) 2. Nonscaphoid carpal fractures 3. Distal ulna fracture II. Precautions 1. Do not plaster over the thenar eminence. 2. Do not extend the plaster beyond the palmar crease. The patient must be able to flex his or her MCPs to 90 degrees. 3. Bony prominences, such as the ulnar styloid, must be well padded. Additional strips of padding may be applied over these potential pressure points. III. Pearls 1. The easiest place to begin is at the wrist. The natural contour of the arm will prevent sliding. IV. Equipment 1. Stockinette: 3 inches 2. Cast padding: 3 inches 3. Plaster: 3 inches 4. Elastic or self-adherent bandage: 3 inches  SHORT ARM CAST V. Basic Technique 1. Patient positioning: a. The elbow should be bent to 90 degrees with the arm upright. b. Supine: 1) Have thin patients move their body all the way to the contralateral side of the stretcher. 2) The patient can then rest his or her elbow on the stretcher. c. Upright: Use a bedside table to allow the patient to place his or her arm at a comfortable level. 2. Where to start: a. Palmar flexion crease 3. Where to finish: a. Mid forearm  SHORT ARM CAST 4. Where to mold (three-point mold): a. For a dorsally angulated or displaced distal radius fracture: 1) Dorsal aspect of carpus 2) Volar distal forearm 3) Dorsal aspect of the mid forearm b. For a volarly angulated or displaced distal radius fracture: 1) Volar aspect of the carpus 2) Dorsal distal forearm immediately proximal to the wrist crease 3) Volar aspect of the mid forearm 5. Steps: a. Prepare a stockinette. b. Position the stockinette. c. Wrap the extremity in cast padding. d. Create three cast padding cuffs. e. Fold the stockinette over both proximally and distally. f. Prepare the plaster roll in the usual fashion. g. Apply the plaster roll. h. Split the cast, if necessary  SHORT ARM CAST VI. Detailed Technique 1. Prepare a stockinette by cutting it into two pieces: a. One piece for the proximal portion at the elbow b. One piece for the distal portion at the hand 2. Position the stockinette: a. Place one stockinette over the elbow with equal lengths on either side. b. Cut a thumb hole in the mid portion of the other stockinette and fit this portion over the hand. c. The stockinette should extend to the PIP joints. 3. 3. Wrap the extremity in cast padding. a. Start at the wrist and circumferentially wrap distally. 1) Use a standard 50% overlap technique. 2) Two layers of padding are sufficient. b. Carefully tear the cast padding so as to conform around the thumb interspace. Do not go past the palmar flexion crease. c. Once the hand has been adequately padded, continue wrapping proximally to the proximal forearm.  SHORT ARM CAST 4. Create three cast padding cuffs: a. Palmar flexion crease/metacarpal heads: This cuff should form a “V” at the ulnar aspect of the hand to allow for the cascade of the digits. b. Thumb: Again, form a “V” at the base of the thumb. c. Proximal forearm: This cuff can be circular.  SHORT ARM CAST 5. Fold the stockinette over both proximally and distally. Ensure that MCP motion is completely preserved. 6. Prepare the plaster roll in the usual fashion. 7. Apply the plaster roll. a. Start at the wrist and work distally. b. Use a twisting motion to get through the thumb interspace. 1) Twist the plaster roll 360 degrees in the interspace. 2) Alternatively, if using fiberglass, the fiberglass can be cut to conform to the thumb interspace.  SHORT ARM CAST c. Roll two more times around the hand and through the thumb interspace. Do not go past the palmar flexion crease. d. Continue the plaster proximally. Use the standard technique of laminating while rolling. e. Ensure that at least three to five layers of plaster are applied. 8. Split the cast, if necessary.  Third topic THUMB SPICA CAST  THUMB SPICA CAST I. Indications for Use 1. Scaphoid fracture (nonacute) II. Precautions 1. Do not extend the plaster beyond the palmar crease. The patient must be able to flex his or her MCP joints to 90 degrees. 2. Bony prominences, such as the ulnar styloid, must be well padded. Additional strips of padding may be applied over these potential pressure points. III. Pearls 1. The easiest place to begin is at the wrist. The natural contour of the arm will prevent sliding. 2. For proximal phalangeal fractures or MCP joint dislocations, a handbased thumb spica cast can be used. a. A hand-based thumb spica cast begins just distal to the wrist crease and extends to cover the entire thumb. b. A hand-based thumb spica cast allows wrist motion. IV. Equipment 1. Stockinette: 3 inches 2. Cast padding: 3 inches 3. Plaster: 3 inches 4. Elastic or self-adherent bandage: 3 inches Basic  THUMB SPICA CAST V. Technique 1. 1. Patient positioning: a. The elbow should be bent to 90 degrees with the arm upright. b. Supine: 1) Have thin patients move their body all the way to the contralateral side of the stretcher. 2) The patient can then rest his or her elbow on the stretcher. c. Upright: Use a bedside table to allow the patient to place his or her arm at a comfortable level. 2. 2. Where to start: a. Thumb: 1) Distal to the interphalangeal (IP) joint for injuries at or distal to the metaphalangeal (MP) joint 2) Proximal to IP joint for injuries proximal to MP joint b. Hand: 1) Proximal to the distal palmar crease  THUMB SPICA CAST 3. Where to finish: a. Upper forearm 4. Where to mold: a. Interosseous mold 5. Steps: a. Prepare a stockinette. b. Position the stockinette. c. Wrap the extremity in cast padding. d. Create three cast padding cuffs. e. Fold the stockinette over both proximally and distally. f. Prepare the plaster roll in the usual fashion. g. Apply the plaster roll. h. Split the cast if necessary.  THUMB SPICA CAST VI. Detailed Technique 1. Prepare the stockinette by cutting it in two pieces: a. One piece is for the proximal portion at the elbow b. One piece is for the distal portion at the hand. 2. 2. Position the stockinette. a. Place one stockinette over the elbow with equal lengths on either side. b. Cut a thumb hole in the mid portion of the other stockinette and fit this portion over the hand. c. The stockinette should extend to the PIP joints. 3. Wrap the extremity in cast padding. a. Start at the wrist and circumferentially wrap distally. 1) Use a standard 50% overlap technique. 2) Two layers of padding are sufficient. b. Carefully tear the cast padding so as to conform around the thumb interspace. Do not go past the palmar flexion crease. c. Tear several strips of cast padding to pad the thumb. d. Once the hand has been adequately padded, continue wrapping proximally to the proximal forearm.  THUMB SPICA CAST VI. Detailed Technique 1. Prepare the stockinette by cutting it in two pieces: a. One piece is for the proximal portion at the elbow b. One piece is for the distal portion at the hand. 2. 2. Position the stockinette. a. Place one stockinette over the elbow with equal lengths on either side. b. Cut a thumb hole in the mid portion of the other stockinette and fit this portion over the had. c. The stockinette should extend to the PIP joints. 3. Wrap the extremity in cast padding. a. Start at the wrist and circumferentially wrap distally. 1) Use a standard 50% overlap technique. 2) Two layers of padding are sufficient. b. Carefully tear the cast padding so as to conform around the thumb interspace. Do not go past the palmar flexion crease. c. Tear several strips of cast padding to pad the thumb. d. Once the hand has been adequately padded, continue wrapping proximally to the proximal forearm.  THUMB SPICA CAST 4. Create three cast padding cuffs: a. Palmar flexion crease/metacarpal heads: This cuff should form a “V” at the ulnar aspect of the hand to allow for the cascade of the digits. b. Thumb: This cuff can be circular distal to the IP joint. c. Proximal forearm: This cuff can be circular. 5. Fold the stockinette over both proximally and distally. Ensure that MP joint motion is completely preserved. 6. Prepare the plaster roll in the usual fashion.  THUMB SPICA CAST 7. Apply the plaster roll. a. Start at the wrist and work distally. b. Use a twisting or pinching motion to get through the thumb interspace. 1) Twist the plaster roll 360 degrees in the interspace. 2) Pinch the roll to narrow it at the web space. c. Roll two more times around the hand and through the thumb interspace. d. Roll around the thumb, being careful not to extend beyond the cast padding. e. Continue the plaster proximally. 1) Use the standard technique of laminating while rolling. f. Ensure that at least three to five layers of plaster are applied.  THUMB SPICA CAST 8. Mold the cast, if desired. An interosseous mold over the forearm should be made by compressing the anterior and posterior surfaces to make the cast more oval and less cylindrical. 9. Split the cast, if necessary. Lower Extremity Splints and Casts Haythem Zein M.D. Orthopedic Two Topics CYLINDE AO R CAST SPLINT First Topic CYLINDER CAST  CYLINDER CAST I. Indications for Use 1. Patellar fractures 2. Patellar dislocations Precautions Be sure to pad the malleoli thickly to avoid pressure sores on the ankle and to limit distal migration of the cast. II. Pearls 1. Have the patient stand with his or her knee in slight flexion, sufficiently straight to walk on but bent enough to be comfortable. III. Equipment 1. Stockinette 2. Cast padding 3. Plaster Basic  CYLINDER CAST IV. Technique 1. Patient positioning: a. The patient is standing. b. The knee is flexed 5 to 10 degrees and the ankle is plantigrade on the floor. 2. Where to start: over the malleoli 3. Where to finish: upper thigh 4. Where to mold: supracondylar femur 5. 5. Steps: 1. a. Prepare a stockinette. 2. b. Position the stockinette. 3. c. Position the patient. 4. d. Wrap the extremity in cast padding. 5. e. Create and apply cast padding cuffs (see Chapter 12). 6. f. Fold down the end of the stockinette at the ankle and thigh. 7. g. Prepare the plaster. h. Apply the plaster. 8. i. Apply the mold.  CYLINDER CAST V. Detailed Technique 1. Prepare a stockinette by cutting it into two pieces: a. One piece is for the proximal portion at the thigh. b. One piece is for the distal portion at the lower leg. 2. Position the patient and place the stockinette segments: a. Place one stockinette over the proximal thigh. b. Place the other over the malleoli.  CYLINDER CAST 3. Wrap the extremity in cast padding. 3. Start at either end and wrap circumferentially. a. Use a standard 50% overlap technique. b. Two layers of wrapping are sufficient. 4. Span the joint line with cast padding at the posterior aspect of the knee (see aforementioned precautions). 5. Apply a thick cuff of cast padding at the ankle.  CYLINDER CAST 4. Create a cast padding cuff for the malleoli. 5. Fold down the end of the stockinette at the ankle and thigh 6. Prepare the plaster. Use the standard technique of wetting and laminating.  CYLINDER CAST 7. Apply the plaster: a. Start at the thigh and work distally. b. Use the standard technique of laminating while rolling. c. Be vigilant about the position of the knee. d. Additional thickness behind the knee can be achieved by adding several precut strips. 8. Apply the mold. Second Topic AO SPLINT I. Overview 1. AO TheSPLINT AO splint is constructed with three plaster slabs: a. A medial slab and a lateral slab in a J-type configuration b. A posterior slab in an L-type configuration 2. The AO splint also can be constructed with two plaster slabs: a. A U-type slab substitutes for the two J-type slabs. b. The posterior slab in an L-type configuration remains unchanged. 3. The technique described for this splint is application without the Quigley maneuver. If the Quigley maneuver is used, the splint is applied in the same fashion but the patient is supine on a stretcher. II. Indications for Use 1. 1. Ankle fractures 2. 2. Pilon fractures IV. Precautions 1. AO SPLINTof the foot in the plaster is of paramount importance. The position a. The equinus position is defined as a foot plantarflexed beyond neutral. b. If the foot is left in an equinus position for a prolonged period, the Achilles tendon becomes contracted and ankle stiffness ensues. 2. Swelling is a significant concern for ankle fractures; the degree of swelling often worsens after 2 to 3 days. a. A bulky cotton padding (variously known as Sir Robert Jones’ cotton, Bulky Jones cotton, and Red Cross cotton) can be applied below the plaster slabs to allow the splint to accommodate the swelling. b. The medial and lateral slabs should be kept slightly posterior on the leg to prevent them from joining at the anterior aspect. If they join both posteriorly and anteriorly, this position creates a circumferential cast construct. V. Pearls 1. Many ankle fractures are reduced with use of the Quigley maneuver. By having the patient keep AO his orSPLINT her leg in extension during the Quigley maneuver, the ankle will naturally be kept out of equinus. 2. For instances in which a reduction maneuver is not used, two techniques can be used to keep the foot out of equinus: a. The patient may lie prone with his or her knee bent to 90 degrees. Gravity will aid but not completely prevent equinus. 1) To completely prevent equinus with the patient prone, use the following technique: i. Cut a 6-foot-long piece of 4- or 6-inch stockinette. ii. Put the stockinette on the patient up to the mid thigh. iii. Have the patient lie prone and flex his or her knee to 90 degrees. iv. Tie the loose end to the end of the bed so the ankle is out of equinus. v. Apply the splint. vi. Once the splint is completely applied, cut the stockinette close to the ends of the splint and tuck the ends under the ACE wrap. 2) This technique typically is used for a child. b. The patient is kept supine while the splint is applied. The hip is slightly flexed, the knee is bent to 90 degrees, and the foot is placed on the surgeon's chest. Axial pressure is applied until the plaster has set. This technique typically is used with unconscious patients.  3. When applying Jones’ cotton, splitting it in half width-wise is useful. Halving the thickness AO SPLINT of the cotton by splitting it longitudinally also is possible. 4. Using cool water and preparing all three plaster slabs in water prior to application of the splint is the easiest technique to use and eliminates the need for an assistant. 5. When applying the medial and lateral slabs, always start at the proximal aspect of the limb. If the splint is long, it can simply be carried up the other side. VI. Equipment 1. 4-inch stockinette 2. 4- or 6-inch cast padding 3. 4- or 6-inch plaster 4. 4- or 6-inch elastic or self-adherent bandage 5. 2-inch silk tape VII. Basic Technique 1. AO SPLINT Patient positioning: a. If the Quigley maneuver is used: The patient is supine on a stretcher with his or her leg elevated by traction. b. If the supine or sitting technique is used: The patient is supine or sitting on a stretcher with the knee and lower leg off the bed. c. If the prone technique is used: The patient is prone on a stretcher with the knee flexed to 90 degrees. 2. Where to start: a. Metatarsal heads 3. Where to finish: a. Tibial tubercle 4. Where to mold for ankle fracture: a. Distal to the lateral malleolus over the calcaneus b. Immediately proximal to the medial malleolus 5. Steps: a. AO SPLINT Measure the length of the splint using plaster. b. Roll out the plaster. c. Roll out the cast padding. d. Position the patient. e. Perform a modified Quigley maneuver to reduce the fracture if necessary. f. Apply Jones’ cotton, if desired. g. Prepare the plaster in the usual fashion. h. Apply plaster slabs. i. Overwrap the plaster slabs with cast padding. j. Definitively secure the splint with an elastic or self-adherent bandage. k. Perform molding and reduction if necessary  AO SPLINT VIII. Detailed Technique: Application Sitting 1. Perform an intra-articular ankle block, if desired. 2. Measure the length of the splint: a. Use the contralateral side if necessary. b. Two different measurements will be taken: a wrap-around U splint measurement and a posterior measurement. 1) Note that two different plaster slabs will be used: one U slab and one posterior slab. 2) Posterior: i. Start immediately distal to the popliteal fossa. ii. End at the metatarsal heads. 3) Lateral: i. Start immediately proximal to the fibular head. ii. End at the medial arch of the foot. 3. Roll out the plaster. a. The plaster slab should be 10 to 12 sheets thick. AO SPLINT b. Two different slabs will be created, with the U slab being approximately 25% longer than the posterior slab. 4. Position the patient: a. The patient should be supine or sitting with the knee and lower leg off the bed and the ball of the foot resting on your knee or thigh. b. Create toe traps using rolled gauze if using modified Quigley traction (see Chapter 11). c. Attach the gauze to the patient's toes using a dual-ring construct: 1) Make a loop of gauze. 2) Place the loop between the web space of the great toe and second toe. 3) While holding one side of the gauze taught, place your other hand into the loop. 4) Spread your fingers and pull upward. 5) Hook each side around the great toe and second finger. 6) Pull the free end taut.  AO SPLINT 5. Apply cast padding (or Jones’ cotton, if desired) a. Start at either end and wrap in a circumferential fashion from the metatarsal heads to the level of the fibular head and tibial tubercle. b. Because of the thickness of the Jones’ cotton, very little overlap is necessary.  AO SPLINT 6. Prepare the plaster in the usual fashion. a. Use the standard technique of wetting and laminating. b. Prepare both slabs at the same time before application. c. Water that is slightly cooler than that used for other procedures should be used. 7. Apply the plaster slabs. a. Begin with the posterior slab. 1) Start at foot and extend proximally. 2) Fold down excess at the knee if it is encountered. b. Apply the U slab. 1) Start proximally at the fibular head and extend distally.  AO SPLINT 8. Overwrap with a single layer of cast padding.  AO SPLINT 9. Definitively secure the splint with an ACE wrap : a. Start at either end and advance to the other end. b. Secure the end with silk tape or Velcro. 10. Perform molding: a. Ankle fracture. b. If no reduction is necessary, apply supramalleolar molding. Thank you Any questions? Lower Extremity Splints And Casts Haythem Zein M.D. Orthopedic Today’s Topics  LONG-LEG SPLINT First Topic LONG-LEG SPLINT LONG-LEG SPLINT LONG-LEG SPLINT LONG-LEG SPLINT LONG-LEG SPLINT LONG-LEG SPLINT  LONG-LEG SPLINT 4. Place a padded crutch beneath the mattress on the stretcher so that only a foot of the top of the stretcher remains visible. 5. Position the patient: a. The patient is supine with his or her pelvis halfway onto the crutch. Make sure the patient and the crutch are secure. b. Allow the limb to hang down, or support it by placing the patient's foot on your thigh. If assistants are available, they can elevate the limb. 6. Apply Jones’ cotton or regular cast padding: a. If using Jones’ cotton, start at metatarsal heads and wrap in a circumferential fashion proximally to the mid thigh with minimal overlap. b. If using standard padding, begin proximally or distally depending on your preference.  LONG-LEG SPLINT 7. Apply the splint. a. Begin with the posterior slab: 1) Start at the foot and extend proximally. 2) Provisionally secure the splint with cast padding at the knee and then the thigh. 3) Fold down any excess splint. b. Apply the lateral and medial wraparound slab: 1) Start proximally at the upper thigh and extend distally. 2) Provisionally secure the splint with cast padding at the thigh and then at the knee. 3) Overwrap with cast padding. LONG-LEG SPLINT 8. Perform a reduction maneuver if required. 9. Definitively secure the splint with an ACE wrap: a. Start at the foot and extend proximally. b. Secure the end with silk tape.  LONG-LEG SPLINT 10. Mold the splint: a. At this point, assistants are no longer necessary. b. The limb is taken by the surgeon, the foot is placed on the thigh, and an axial load is applied to ensure the foot is not in equinus. 1) This position naturally places the knee at approximately 30 degrees of flexion. 2) Perform either a supramalleolar mold or a supracondylar mold or both.  LONG LEG CAST Second Topic LONG LEG CAST LONG LEG CAST LONG LEG CAST LONG LEG CAST LONG LEG CAST VI. Detailed Technique 1. Prepare a stockinette by cutting two pieces: a. One piece is for the proximal portion at the thigh. b. One piece is for the distal portion at the foot. 2. Position the stockinette: a. Place one stockinette over the proximal thigh. b. Place the other stockinette with equal lengths centered over the metatarsal heads 3. Position the patient. a. Place a padded crutch beneath the mattress on the stretcher so that only 1 foot of the top of the stretcher remains visible. b. The patient is supine with his or her pelvis halfway onto the crutch. Make sure the patient and the crutch are secure to prevent a fall. c. Allow the limb to hang down or support it by placing the patient's foot on your thigh. If available, an assistant can elevate the limb. d. If the patient is anesthetized, bring the patient to the edge of the bed and drape the extremity over the side with an assistant holding the leg.  LONG LEG CAST 4. Wrap the extremity in cast padding. a. Start at the thigh and circumferentially wrap distally. 1) Use a standard 50% overlap technique. 2) Two layers of wrapping are sufficient. b. Span the joint line with cast padding at the posterior aspect of the knee (see aforementioned precautions).  LONG LEG CAST c. Continue distally to around the foot: 1) Span the joint line with cast padding at the ankle (see aforementioned precautions). 2) Do not cover the heel at this point. d. Once sufficient padding has been wrapped around the malleoli and the foot, the heel can be addressed. e. Tear 4-inch strips of cast padding and lay them on top of the heel. Repeat several times to ensure sufficient padding. LONG LEG CAST 5. Create a cast padding cuff for the metatarsal heads. This cuff should form a V at the lateral aspect of the foot to allow for the cascade of the digits. 6. Fold down the end of the stockinette at the foot and thigh. 7. Prepare the plaster. Use the standard technique of wetting and laminating. LONG LEG CAST  Any questions? Thank you Lower Extremity Splints and Casts Haythem Zein M.D. Orthopedic Two Topics PATELLAR SHORT-LEG TENDON CAST BEARING (PTB) CAST SHORT-LEG CAST First Topic  SHORT-LEG CAST I. Indications for Use 1. Ankle fractures (nonacute) 2. Achilles tendon rupture (in equinus) II. Precautions 1. The position of the foot in the plaster is of paramount importance. a. The equinus position is defined as a foot plantarflexed beyond neutral. b. If the foot is left in an equinus position for a prolonged period, the Achilles tendon becomes contracted and ankle stiffness ensues. c. When a short leg cast is used for an Achilles tendon rupture, 10 to 15 degrees of equinus is desirable, and an optional heel can be built into the cast to facilitate weight bearing in the cast while maintaining equinus. 2. At the anterior aspect of the ankle, do not allow edges of cast padding to lay immediately within the joint line. a. Allowing edges of cast padding to lay immediately within the joint line will create wrinkling and can lead to skin breakdown in this very fragile area. b. Span the area by having the mid-point of the cast padding roll directly over the ankle flexion crease; by doing so, the cast padding will be slightly tented above the joint line and will not be in direct contact with the skin, thus reducing the risk of skin breakdown.  SHORT-LEG CAST III. Pearls 1. Raise the stretcher as high as it will go to make application of the cast easier. 2. Keeping the foot out of equinus sometimes can be difficult. If no reduction is necessary, placing the patient in a prone position can facilitate proper positioning of the ankle: a. The patient may lay prone with his or her knee bent to 90 degrees. Gravity will aid but not completely prevent equinus. b. To prevent equinus with the patient prone, use the following technique: 1) Cut a 6-foot-long piece of a 4- or 6-inch stockinette. 2) Put the stockinette on the patient up to the mid thigh. 3) Have the patient lay prone and flex his or her knee to 90 degrees. 4) Tie the loose end to the end of the bed so the ankle is out of equinus. 5) Apply the splint. 6) Once the splint is completely applied, cut the stockinette close to the ends of the splint and tuck the ends under the elastic bandage.  V. Equipment 1. 4-inch stockinette 2. 4- or 6-inch cast padding 3. 4- to 6-inch plaster or fiberglass VI. Basic Technique 1. Patient positioning: SHORT-LEG a. The patient is sitting off the end of the bed. Ensure that at least half the thigh is off the bed to allow for space CAST between the leg and the bed. b. Alternatively, the patient may be placed prone with the knee flexed to 90 degrees. 2. Where to start: a. Metatarsal heads 3. Where to finish: a. Tibial tubercle SHORT-LEG CAST 4. Where to mold: a. No reduction: supramalleolar mold b. Ankle fracture: 1) Distal to the lateral malleolus over the calcaneus 2) Immediately proximal to the medial malleolus 5. Steps: a. Position the patient. b. Prepare a stockinette. c. Position the stockinette. d. Wrap the extremity in cast padding. e. e. Create two cuffs of cast padding (see Chapter 12). f. f. Fold down the two ends of the stockinette. g. g. Prepare the cast material. h. h. Apply the cast material. i. i. Apply molding or a reduction as needed. j. j. Split the cast if necessary. SHORT-LEG CAST VII. Detailed Technique 1. Position the patient: a. The patient is sitting upright and the leg is freely off the end of the bed. b. Make sure the patient is sitting far enough forward so there is sufficient room between the posterior calf and the end of the bed. 2. Prepare a stockinette by cutting it into two pieces: a. One piece is for the proximal portion at the knee. b. One piece is for the distal portion at the foot.  SHORT-LEG CAST 3. Position the stockinette segments (Figure 14-64): a. Place one stockinette segment over the knee with equal lengths on either side. b. Place the other segment with equal lengths centered over the metatarsal heads. 4. Wrap the extremity in cast padding: a. Start at the level of the tibial tubercle and circumferentially wrap distally to the area immediately above the lateral malleolus. 1) Use a standard 50% overlap technique (see Chapter 12). 2) Two layers of wrapping are sufficient.  SHORT-LEG CAST b) Span the joint line with cast padding at the anterior aspect of the ankle (see aforementioned precautions) (Figure 14- 65). c) Return to the lateral malleolus and wrap over this area. d) Continue distally to around the foot (see Figure 14-33). Do not cover the heel at this point. e) Once sufficient padding has been wrapped around the malleoli and the foot, the heel can be addressed. f) Tear 4-inch strips of cast padding and lay them on top of the heel (Figure 14-66). Repeat several times to ensure sufficient padding.  SHORT-LEG CAST 5. Create two cast padding cuffs (see Chapter 12): a. Metatarsal heads (see Figure 14-35): This cuff should form a “V” at the lateral aspect of the foot to allow for the cascade of the digits. b. Tibial tubercle (Figure 14-67): This cuff can be circular. 6. Fold down the two ends of stockinette (see Figure 14-36). 7. Prepare the plaster. Use the standard technique of wetting and laminating (see Chapter 12).  SHORT-LEG CAST 8. Apply the plaster. a. Start at the tibial tubercle and work distally (Figure 14-68). Use the standard technique of laminating while rolling (see Chapter 12). 1) Be vigilant about the position of the foot (Figure 14-69). 2) Additional thickness over the plantar aspect of the foot can be achieved by adding several precut strips, if desired. 9. Apply molding or perform a reduction as needed. 10. Split the cast if necessary. PATELLAR TENDON BEARING (PTB) CAST Second Topic  PATELLAR TENDON BEARING (PTB) CAST I. Indications for Use Low tibial shaft fractures Precautions 1. The position of the foot in the plaster is of paramount importance. a. The equinus position is defined as a foot plantarflexed beyond neutral. b. If the foot is left in an equinus position for a prolonged period, the Achilles tendon becomes contracted and ankle stiffness ensues. 2. At the anterior aspect of the ankle, do not allow edges of cast padding to lay immediately within the joint line. a. Allowing edges of cast padding to lay immediately within the joint line will create wrinkling and can lead to skin breakdown in this very fragile area. b. Span the area by having the mid-point of the cast padding roll directly over the ankle flexion crease; by doing so, the cast padding will be slightly tented above the joint line and will not be in direct contact with the skin, thus reducing the risk of skin breakdown.  PATELLAR TENDON BEARING (PTB) CAST II. Pearls 1. Raise the stretcher as high as it will go to make application of the cast easier. 2. Keeping the foot out of equinus sometimes can be difficult. If no reduction is necessary, placing the patient in a prone position can facilitate proper positioning of the ankle: a. The patient may lay prone with his or her knee bent to 90 degrees. Gravity will aid, but not completely prevent equinus. b. To prevent equinus with the patient prone, use the following technique: 1) Cut a 6-foot-long piece of 4- or 6-inch stockinette. 2) Put the stockinette on the patient up to the mid thigh. 3) Have the patient lie prone and flex his or her knee to 90 degrees. 4) Tie the loose end to the end of the bed, such that the ankle is out of equinus. 5) Apply the splint. 6) Once the splint is completely applied, cut the stockinette close to the ends of the splint and tuck the ends under the elastic bandage. PATELLAR TENDON BEARING (PTB) CAST III. Detailed Technique 1. Position the patient as for a short leg cast. a. The patient is sitting upright and the leg is freely off the end of the bed. b. Make sure the patient is sitting far enough forward so there is sufficient room between the posterior calf and the end of the bed. 2. Prepare a stockinette by cutting one piece of the stockinette for the distal portion at the foot. 3. Position the stockinette. 4. Wrap the extremity in cast padding. a. Start as proximal as possible on the lower leg and circumferentially wrap distally to the area immediately above the lateral malleolus. PATELLAR TENDON BEARING (PTB) CAST 1) Use a standard 50% overlap technique. 2) Two layers of wrapping are sufficient. b. Span the joint line with cast padding at the anterior aspect of the ankle (see aforementioned precautions). c. Return to the lateral malleolus and wrap over this area. d. Continue distally to around the foot. Do not cover the heel at this point. e. Once sufficient padding has been wrapped around the malleoli and the foot, the heel can be addressed. f. Tear 4-inch strips of cast padding and lay them on top of the heel. Repeat several times to ensure sufficient padding.  PATELLAR TENDON BEARING (PTB) CAST 5. Create two cuffs of cast padding: a. Metatarsal heads: This cuff should form a “V” at the lateral aspect of the foot to allow for the cascade of the digits. b. Patellar tendon: Make sure that knee motion is unimpeded. 6. Fold down the end of the stockinette. 7. Prepare the plaster. Use the standard technique of wetting and laminating.  PATELLAR TENDON BEARING (PTB) CAST 8. Apply the plaster: a. Start at the patellar tendon and apply a strip of 2-inch plaster over the anterior-proximal shin. b. Staying out of the popliteal fossa, wrap circumferential plaster to cover the strip of plaster c. Continue wrapping as per a short leg cast. Use the standard technique of laminating while rolling 1) Be vigilant about the position of the foot. 2) Additional thickness over the plantar aspect of the foot can be achieved by adding several precut strips, if desired.  PATELLAR TENDON BEARING (PTB) CAST 9. Apply supramalleolar molding. 10. Make sure the cast does not limit knee flexion or extension..‫استخدم قال ًبا فوق الكاحل‬.‫تأكد من أن الجبس ال يحد من ثني الركبة أو تمديدها‬ Thank You Any Questions? Lower Extremity Splints and Casts Haythem Zein M. D. Orthopedic HIP SPICA CAST I. Overview 1. The hip spica cast is one of the most difficult casts to apply. 2. The hip spica cast generally is composed of an abdominal portion attached to long leg casts, which is a so-called “double spica cast.” When the unaffected extremity is placed into a thigh-only cast, the cast is termed a “11 ⁄2 spica cast.” A “single leg” hip spica cast is composed of an abdominal portion attached to a single long leg cast of the affected leg. All three types of spica casts have been shown to be successful in treating diaphyseal femoral fractures in children younger than 6 years. I. Overview 3. The following points regarding the application of a hip spica cast are controversial: a. The type of spica cast that should be used (double, 11 ⁄2, or single leg) b. Whether the foot should be included in the cast c. When to apply traction while casting d. Whether to apply the abdominal or the leg portion of the cast first e. Positioning of the extremity II. Indications for Use 1. Pediatric femur fractures 2. General indications for type of spica cast: a. Double spica cast: concomitant pelvic or hip injury b. 11 ⁄2 spica cast: 1) Proximal or mid diaphyseal femoral fractures 2) Older children c. Single leg spica cast: distal femoral fractures  III. Precautions 1. The following complications of hip spica casting may occur: a. Compartment syndrome has been reported in the 11 ⁄2 spica cast with the hip and knee flexed to 90 degrees. b. Femoral and peroneal nerve palsy can occur, respectively, from excessive hip flexion and valgus molding over the fibular head. c. Skin breakdown and decubitus ulcers can occur. d. Superior mesenteric artery syndrome can occur from excessive thoracolumbar lordosis in the abdominal portion of the cast. 2. Close monitoring of the patient for complications is necessary during the first 2 weeks after application of the cast. 3. Some authors argue that initial femoral shortening greater than 2 cm is a contraindication for treatment with a spica cast. 4. Families caring for children with spica casts must contend with numerous psychosocial issues, such as transportation and bathing.  IV. Pearls 1. We prefer a relaxed leg position with the knee at 60 degrees of flexion and the hip in 45 degrees of flexion rather than the traditional 90-90 position. An assistant should help the patient maintain this position throughout the application of the cast to avoid any bunching or creasing of the casting material. 2. Application of the cast can be performed in the emergency department with use of conscious sedation or in the operating room (OR) with use of general anesthesia. 3. Although they may not always be available, use of waterproof Gore-Tex pantaloons and a cast liner significantly improves the ability of the family to care for a child with a spica cast. 4. A broomstick, a twisted bar of fiberglass casting material, or some other connecting bar can be used to confer additional stability and strength to the spica cast. 5. Placing the spica table into a 10 degrees of reverse Trendelenburg position, either by tilting the operating table or by placing a block of wood under the spica table, allows the child's perineum to fit snugly against the perineal post of the spica table  V. Equipment 1. Hip spica table 2. Two to four blue OR towels (or a towel folded so it is 2 inches thick) 3. A stockinette, with the size depending on the size of the child; typically, a 2-inch stockinette is used for the leg portions and either a 3-, 4-, or 6-inch stockinette is used for the abdominal portion. 4. A sawed-off portion of a broomstick or a fiberglass bar 5. 4-inch cast padding 6. 4-inch fiberglass or plaster cast rolls  VI. Basic Technique: 11 ⁄2 Spica Cast 1. Patient positioning: 1. The patient should be placed on the hip spica table. a. The buttocks and perineum should be placed on the adjustable post. b. The thoracic spine should sit on the table extension. c. The shoulders and thorax should be on the platform portion of the table. 2. The knee should be held at 60 degrees of flexion and the hip in 45 degrees of flexion. The hip should be abducted 20 to 30 degrees and the extremity should be externally rotated 15 degre