A method of temporary immobilization for a variety of musculoskeletal disorders involving bones, tendons, muscles, and other tissues. It is a hard-covering that is used to support fractured arms, legs, or other body parts. Casts are made of two types of materials:
- Plaster of Paris: gypsum (calcium sulfate dihydrate) is the precursor.
- White in color
- Dries in 1 to 3 days. When dried, it becomes shiny and white
- Not water resistant.
- Synthetic Fiberglass: a resin cast; the cast is filled with a polymer fluid which then hardens. It is a type of “moldable plastic” which may come with various colors, patterns, or designs.
- Dries in 20 to 30 minutes, but may require up to 24 hours to fully harden.
- Water resistant
- Lighter, cooler, and waterproof compared to plaster of paris.
Characteristics of a Good (POP) Casting
- White and Shiny
- Odorless
- Light in weight
- Not too tight nor too loose
- Resonant upon percussion
Purposes of Casting
- Correct deformity
- Immobilize a bone during healing
- Immobilize a bone after surgery
- Support, maintain, and realign a bone
- Prevent or decrease muscle contractions
- Serve as a mold of a limb in making an artificial limb
Types of Casts
- Unilateral Hip Spica Cast
- One-and-One-Half Hip Spica Cast with an abduction bar
- Bilateral Long-leg Hip Spica Cast with an abduction bar
- Short-Legged Hip Spica Cast from the chest to the thigh or knees
- Walking Cast: affectation of tarsals and metatarsals with callus formation
- Basket Cast used for massive bone injury of the patella to facilitate wound dressing.
- Patellar Tendon Bearing Cast affectation of tibia-fibula with callus formation
- Quadrilateral/Ischial Weight Bearing Cast: affectation of the shaft of femur with callus formation
- Pantalon Cast: affectation of the pelvis.
- Delvit cast: affectation of the 1/3rd of the tibia-fibula with callus formation.
- Cast brace: fracture of the distal 1/3rd of the femur and proximal 1/3rd of the tibia with callus formation.
- Body Cast: encircles the trunk, stabilizing the spine. Used for affectation of the lower dorsolumbar spine.
- Minerva Cast: applied around the neck and trunk of the body. Used for affectation of the cervical and upper dorsolumbar spine.
- Rizzer’s Jacket Cast: used in the affectation of the thoracolumbar spine and scoliosis (esp. S-shaped variations)
- Shoulder Spica Cast: applied around the trunk of the body then the shoulder, arm, and hand. Used for the affectation of the humerus and shoulder joint.
Cast Techniques
- Bivalving: cutting the cast into two halves from the upper to bottom portion to relieve tightness of the casted extremity.
- Windowing: creating a “window” on a cast on the site of a wound or such for the purpose of visualization, care, medication, etc.
- Reinforcing: reapplication of POP to regain strength when instabilities (getting POP wet, cracks, breaks) are found.
- Petalling: pulling the stockinet over the cast, wrapping it around the rough edges of the cast, providing protection for the skin. A 4” piece of tape is wrapped half inside and half outside the cast.
Guidelines of Casting
- Required Materials for Casting
- Pail of water (room temp), where POP is submerged
- Stockinet: used to protect the skin
- Wadding/Padding Sheet: used as padding
- Bandage Scissors: used to cut the sheets/stockinet
- Trimming Knife: used to smoothen the edges of the cast
- Newspaper: used to protect the floor or area
- Disposable Gloves
- Plaster of Paris or Fiberglass: casting materials
- Required Materials for Removal of Casting:
- Stryker Cast Cutter: used for bivalving, windowing, and removal of cast.
- Cast Spreader: used to spread a bivalved cast.
- General Procedure:
- Apply Stockinet for skin protection
- Apply Wadding/Padding Sheet: gives room for the arm to move very slightly.
- Apply the Fiberglass or the Plaster Cast
- Principles of Casting:
- Apply stockinet and padding first before applying a cast
- Apply cast by including the joint above and the joint below the affected part
- Apply cast in circular motion and smoothen with the palm (not with fingertips to avoid uneven indentation)
- Support with the palm and not the fingertips
- 8” (thigh), 6” (leg), 4” (forearm)
- Considerations During Drying:
- Keep the cast uncovered to dry.
- Check for cracks or breaks in the cast.
- Keep the cast always clean.
- Turn the patient every 2 hours while the cast dries
- Prevent any indentation in the cast due to pressure
- Avoid resting the cast on hard surfaces or sharp edges
- Do not use the abduction bar in lifting or carrying the patient. (Abduction bars are used to hold muscles, tendons, bones in place)
- Place a plastic lining at the edge of the cast if the cast is near the groin to avoid soiling and wetting the cast.
Cast Care Instructions and Health Education
- Nursing Interventions:
- Assess the alarming signs and complications of casting body and extremities.
- Assess neurovascular status hourly during the first 24 hours.
- The patient may ambulate with the use of assistive devices.
- Maintain cast hygiene and dryness. Do not allow patients or nurses to write on casts while in admission.
- Report presence of cracks or breaks in the cast
- Rough edges should always be padded to protect the skin from irritation
- Padding is added and taped on.
- Avoid using any objects in scratching the skin under the cast.
- A hairdryer set to cool air may relieve itchiness. Do not blow hot or warm air into the cast as this may cause sweating.
- Avoid putting powders or lotions inside the cast.
- Cover the cast while eating to avoid any spills or crumbs to enter the cast.
- Elevate the cast on a cloth-covered pillow above the level of the heart to decrease swelling
- If for legs, 6” to 10” or on a 45 degree elevation.
- Encourage the client to move digits to promote circulation.
- Do not use the abduction bar in turning, lifting, or carrying the patient.
- Report any alarming signs:
- Fever: 36.5°C to 37.5°C is normal. Drink fluids, regular IVF, wear light clothing.
- Pain: always the first sign to be assessed during cast care using a pain scale (don’t use 1 to 10??)
- Swelling
- Drainage
- Discolorations on the distal limb (cyanotic, pallor)
- Numbness or tingling sensation (paresthesia)
- Cold fingers or toes: skin should be warm to touch.
Complications of Casting
- Necrosis, Pressure Sores, and Nerve Paralysis as a result of inappropriate pressure of the cast on the neurovascular components and bony prominences.
- Compartment Syndrome is a resultant vascular insufficiency and nerve and muscle compression due to unrelieved swelling and can cause irreversible damage to the extremity.
- Pain
- Puffiness in the limb or swelling
- Pallor (or discoloration)
- Pulselessness or persisting cold feel
- Paresthesia
- Paralysis of nerves or absent/diminished sensation
- Multisystem Problems as a result of Immobility:
- Digestive: anorexia, constipation, nausea, vomiting, abdominal distention
- Respiratory: pneumonia, respiratory atelectasis
- Urinary: UTI, renal and bladder calculi may also form
- Circulatory: thrombophlebitis and pulmonary embolus
- Psychological: depression, anxiety
- Delayed Complications:
- Malunion, where bone heals in a disfigured manner.
- Nonunion, where bones do not reattach.
- Delayed Union, where bone healing takes longer than normal.
Procedure
- Identify the patient
- Explain the procedure
- Perform hand washing
- Assess for Pain
- Is there pain? Is it progressive?
- Is pain present during passive extension?
- Where is the pain? Describe its character (local, generalized, soreness, stabbing, throbbing) and intensity (mild; 1-3, moderate; 4-7, severe; 8-10).
- How long has pain been present? When did it start?
- What causes or exacerbates pain? What relieves pain?
- Pain Management:
- Elevate the involved part (decrease swelling and promote venous return)
- Apply cold packs.
- Administer analgesic agents as prescribed.
- Assess for Circulation
- Capillary Refill: apply pressure on digit nail. Color should return within <2 seconds.
- Temperature of the Skin: should be warm to touch
- Assess for Neurovascular Function
- Numbness or Tinging Sensation (Paresthesia)
- Absent or Diminished Sensation
- Ask the patient if they are able to move the digits of the extremity.
- Ask the patient for presence of paresthesia
- Ask the patient if they are able to feel the nurse touching their digits (with a pen). Inability to do so may indicate nerve paralysis.
- Assess for Infection
- Check for swelling above and below the cast.
- Check for presence of a foul odor in the casted extremity.
- Check for drainage and note for color, amount, and odor. Mark the perimeter of the stains on the cast to gauge any increases in drainage.
- Fever
- Provide the client with findings and document the findings.