Casting

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Casting
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plaster of Paris

• Naturally occurring substance derived from
  gypsum.
• When gypsum heated to 128 C, water evaporates
  leaving plaster of Paris
• When water added to dry plaster of Paris,
  molecules are added to gypsum producing a hard
  cast.
• The hydration process gives up kinetic energy
  causing heat.

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Types of Casts

• Bivalved - Can be removed
• secured with Velcro
• Drop out cast - part of the extremity can be
  moved
• cylindrical cast - typical fx cast
• weight bearing casts - to hold extremity in
  position to assist in weight bearing

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Indications for casting

• Spasticity
• soft tissue contracture
• AROM PROM limitations
• Pathologic reflexes
• at least 10 degrees limitation of ROM

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Advantages of casting over splinting

• Excellent conformability, thus decrease
  possibility of pressure sore
• Absorbs sweat because it is porous
• Neutral warmth

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Precautions

• Agitated pts at risk for skin breakdown
• plaster safer than fiberglass for this population
  since fiberglass splinters
• Bony prominences must be protected
• Cast cutters can abrade skin during cast removal
• Improper casting can cause neuropathies
• Casting too tightly can cause edema
• Dont weight bear for 24 hours to allow cast to
  harden
• Pts with communication difficulties may not be
  able to express pain or problems

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(Precautions Cont.)

• Some pts sensitive to plaster. Do sensitivity
  test with small amount of plaster if pt has
  sensitive skin.
• Plaster of Paris can burn skin if
• water temp used to dip the material in is gt 240
  C.
• the cast is gt 8 ply
• a pillow is used over the cast while setting
  which prevents heat dissipation
• casting material is not immersed in water for
  adequate amount of time
• cast is exposed to sun for more than 20 minutes
• Extreme wrist extension can cause CTS

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Contraindications

• Severe Heterotrophic Ossification
• HO
• skeletal muscle rigidity
• it may increase their tightness
• Open wounds or skin grafts
• Edema
• Subluxations of carpal bones
• Impaired circulation
• Severe plasticity - may tear tissue and cause
  compartment syndrome

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(Contraindications Cont.)

• lack of consent from pt, parent, or MD
• sensory problems
• unstable fxs
• pathologic inflammatory conditions including
  arthritis
• if pts at risk for injuring themselves from cast
• Unstable intracranial pressure
• cast is an isometric contraction and may increase
  pressure

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(Contraindications Cont.)

• Contracture existing longer than 6 months
• Poor compliance/attendance as an outpatient
• Metastatic disease due to the risk of fracturing
  with serial casting
• Internal fixation device limits ROM

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Serial or Inhibitory Casting for Neurological
Spasticity

• Cylindrical cast
• Provides neutral warmth plus stretch
• Cutaneous stretch receptors rapidly adapt causing
  inhibition
• Provides more even skin pressure
• Remains in place up to 7 days
• Or, changed as joint motion occurs
• Need 2 people to do this cast
• 1 to hold, 1 to apply cast

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Serial or Inhibitory Casting for Neurological
Spasticity cont.

• Problems can develop quickly since spastic
  extremity is constantly pushing against splint
• Plus you cannot see the problem area
• Pressure areas can develop
• Effects on plasticity is questionable
• some pts experience a rebound effect

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Techniques

• Test and document skin
• condition, circulation, sen-
• sation prior
• to making cast
• Use a flat hand technique
• to avoid finger impressions
• Stretch joints or perform inhibiting/facilitating
  techniques just prior to casting

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Comparison of plaster to
fiberglass

• Longer drying time
• more prone to indentations that can lead to
  breakdown
• stronger
• heavier
• less costly

• Shorter drying time
• higher risk of splintering
• harder
• lighter
• more resistant to dirt
• more durable
• more costly

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Casting Equipment

• Cast Spreader
• Cast Scissors
• Bandage Scissors
• Cast Saw

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Cast Application Guidelines

• Protect floor with newspaper or plastic
• Protect pts face, clothes skin with towels
• Precut stockinet 4-6 longer than length of cast
  on each end so it can be rolled back over cast
• Fill bucket with water
• clean dry skin thoroughly

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• Apply stockinet smooth wrinkles
• Decide on cast length
• 1-2 below axilla and to just proximal to ulnar
  styloid for long arm cast
• 1-11/2 from elbow to just proximal to MP for
  wrist splint
• Open casting material - fiberglass 1 at a time
  applied within 1 minute
• Apply 1 layer of cotton padding in spiral fashion
  with 1/2 overlapping layers in figure 8 over
  elbow or knee

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• Apply felt padding to bony prominences
• add 2-3 more layers of cotton padding
• apply padding 1-2 longer than both ends of cast
• Don plastic gloves
• Put petroleum jelly, lotion or liquid soap to
  gloves to prevent material sticking to gloves.
  Continue to apply throughout casting procedure
• Apply plaster or fiberglass prox to distal in
  spiral fashion
• Fiberglass should overlap by 1/2 a tape length

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• Instruct the patient not to move hand/arm
• Excessive movement can cause creases or ridges
  which can cut skin
• Dip plaster and slightly wring water out (hold
  ends or crimp for ease of use)
• dip 5-6 times until it bubbles
• dont remove too much water

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• Apply 4-5 layers of plaster, 3-4 layers of
  fiberglass
• just slightly overlapping
• smooth in a circular motion between layers
• Avoid pressing fingers or holding on one spot of
  the cast for prolonged periods
• Before last layer, pull stockinet out and turn
  down onto the cast. Apply casting tape just
  below this edge to create a smooth soft edge
• Hold cast in correct position until it dries

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Fold last layer of stockinette and padding over
cast and add several strips of plaster over this
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• Check pulse at points distal to cast after
  application

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Monitor Cast q 2 hours for first 24 hours

• Pain
• Edema
• Sensory changes
• Circulatory Changes - check pulse points distally
  
• Increase or Decrease movement in cast
• Skin integrity
• Severe itching
• Cracks, dents, or softening of cast

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Cast Length

• Long Arm -
• Proximally 1-2 inches below axilla
• Distally just proximal to ulnar styloid
• Wrist
• Proximally 1-1/2 proximal to the elbow joint
• Distally just proximal to the MCPs

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Care of Cast

• Dont get it wet
• Cover with plastic bag if bathing

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Cast Removal

• Use of cast saw
• Select line to cut away from bony prominence
• Put goggles on patient and you
• If patient has trachea or pulmonary problems
  consider mask or way to keep dust away from
  patient
• You can soak a plaster cast in water and it will
  melt away

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• Press cast saw all the way through one site at a
  time
• Spread cast with spreaders
• Cut padding and stockinet with bandage scissors