SPLINTING AND

CASTING - I
BY : DR MAWUKO FELIX
-MBChB
-Orthopedic surgeon ( MUK )
FUNDAMENTALS OF SPLINTING
AND CASTING PROCEDURES
OUTLINE :
• Introduction and • Purposes of casting
Terminology • Selection of cast supplies
• Injury Assessment • Pre-casting procedure
• Purposes of Splinting • Casting procedure
• Selection of splint • Patient instructions
supplies • Cast removal
• Pre-splinting procedure • Specific cast-cutting
• Splinting procedure procedures
• Patient instructions
INTRODUCTION/
TERMINOLOGIES
• Why are the fundamentals of casting and splinting techniques important?

- safety

- management of various orthopedic conditions

TERMINOLOGIES
1.CAST ;
- hard circular dressing with soft padding in- side of it used to immobilize body
parts.
- It immobilizes and protects until healing occurs.
- It is usually made from Plaster of Paris or fiberglass materials.
2. Cast tape : A fast-drying adhesive or resin-impregnated mesh used for
orthopaedic casting

3. Cast padding. A cotton or synthetic roll of material used to pad orthopaedic

casts and splints

4. Exotherm. The heat given off from a setting cast or splint that is made of Plaster
of Paris or fiberglass products.
- caution to prevent exotherm from burning the skin of a patient.
TERMINOLOGY cont’
• Ortho-Glass. A fiberglass splinting system that provides strength and durability in a
padded splint.
- in rolls and precuts in 1-in., 2-in., 3-in., 4-in., 5-in., and 6-in. widths with various lengths.
• Malleolus/Olecranon process.

• Splint. A half cast used to temporarily immobilize and protect body parts.
– deep layer of soft padding next to the skin,
- middle layer of rigid fiberglass or Plaster of Paris,
- superficial layer of compression wrap securing it to the patient. Also, an It may be an
orthotic.

- COMPARTMENT SYNDROME :
- Volkmann’s contracture. Occurs when there is a lack of blood flow (ischemia) to the
forearm
CAST TAPE
SPLINTING

A splint Is a device used for support or immobilisation of a limb

or spine.

Any Material Used to support a fracture is a splint

• Conventional
• Non Conventional

.
FU NC TIO NS / PURPOSE OF
SPLINTING
• Temporary immobilization of sprains, fractures, and
reduced dislocations

• Control of pain

• Facilitates patient transportation

• Prevention of further soft tissue or neurovascular injuries

• Decreases risk of converting a minor injury to a major injury

 INDICATIONS FOR SPLINTING
• Fractures
• Sprains
• Joint Infections
• Tenosynovitis
• Acute Arthritis/Gout
• Lacerated wounds over Joints
• Puncture wound or animal bite over the hand and feet
• To Stabilize or rest the Joint in Ligamentous injury
• To correct deformity
• To Support and immobilize joints post op.
CONTRAINDICATIONS OF
SPLINTING

• Need for urgent open reduction

• Compartment syndrome

• Skin at high risk of infection*

PREPARATION
• Define injury and what splint is required

• Splint in position of function

• Clean and repair skin lesions prior to splint application

• Document neurovascular examination before splint application

• Anticipate ability for the patient to remove clothes after splint

is
applied
SELECTION OF SPLINT
SUPPLIES
PADDINGS:
• For prefabricated splinting materials (Ortho-Glass®),
- cast padding not required.
- Decrease bulk.
- Cast padding should be utilized when the technician must fabricate a
splint from separate materials.

3 types of cast padding:

a.COTTON (easy to apply, tears easily, and self-bonds to create a
smooth undercast surface)

b. SYNTHETTIC- non absorbent (stretch allows narrow widths

around small anatomies without cutting or tearing ).

c. WTER RESISTANT :as fibre glass cast tape ( patient can shower)
contraindication: wound.
Abrssions, incisonal sites
 Padding
• Simple cotton
– The cheapest
– The most commonly used
– Can be applied under both plaster and
fiberglass cast material.
• Synthetic materials
• Newer waterproof liners and
padding
– Much more expensive
– Variable water resistance
SELECTION OF SPLINT
SUPPLIES cont’
• The width of the splint and cast padding determined by:
- The width of the patient’s hand at the MCP joints (upper
extremity)
- foot at the MTP joints (lower extremity).

CAST PADDING AND SPLINT SIZE

PAED : 1-in. to 2-in. cast padding and splint mate- rial),
ADULTS : (3-in. to 4-in. cast padding and splint material

• Stockinette
-contraindication: swelling present or likely
SELECTION OF SPLINT SUPPLIES cont’
• FIBREGLASS SPLINTS + cast tape
- faster setting time
- pad edges of fiberglass cast tape.( 7layers for
fabrication )

• PLASTER :
- extra time/days needed for optimum rigidity
- 10 -15layers should be used

• PREFABRICATED SPLINTS
- In roll that can be custom measured
MATERIALS
USED
• Plaster of Paris(POP)

• Fiberglass(Orthoglass)
Rapid action (20mins)
stronger
lighter
Water resistant
 Splinting Material
• Plaster of Paris
– Made from gypsum - calcium sulfate
dehydrate

– Exothermic reaction when wet - recrystallizes (can

burn patient)

– Average setting time : 3-10 min

– Average drying time : 24-72 hours

 Selecting the Appropriate Cast
Material
• When to Use POP:
– When a well-molded cast is crucial to maintain reduction
• Acute paediatric forearm fractures that requires closed reduction and
immobilization
• Clubfoot
– The immobilized limb is small
– Maintaining position is essential
– Life span of each cast is short.
– In the busy nonsurgical fracture clinic
• Many casts are regularly applied
• Plaster might be chosen for both its increased pliability and its lower
cost.
 PO
P
• Advantages:
– Less expensive
– More moldable than synthetic
counterparts
– More pliable
• Can be effectively spread after the
cast is univalved
 PO
P
• Disadvantages:
– Poor resistance to water
– Relatively low strength-to-
weight ratio
• Heavier (thicker) casts
 Selecting the Appropriate Cast
Material
• When to Choose Fiberglass:
– When cast immobilization is used simply to offer
support and hold a limb in an anatomic position
e.g. in stable minimally displaced fractures.
– For postoperative casting
• After the initial postoperative edema has abated.

• Advantages:
– High strength-to-weight ratio allows for easier mobilization
postoperatively
– Durability is ideal for walking casts
 Synthetic Fiberglass
Materials
• Advantages:
– Lightweight, yet strong
– May be combined with
waterproof liners to allow bathing
and swimming in the cast.
– Often more radiolucent than
plaster
• Better imaging within the cast.
– Lower risk of thermal injury:
• Less material is required
• Very low amount of thermal energy
is released during the curing process.
 Synthetic Fiberglass
Materials
• Disadvantages:
– More expensive.
– More difficult to mold
• More stiff
– Higher risk of pressure on
and constriction of the limb.
– Carcinogenic risk (??)
 Beware!
• Do not use a fiberglass cast in the acute setting
unless the patient will be under close observation
in the hospital.

• Never use it in the acute setting on an obtunded

patient.
Prefabricated splints
• Plastic shells lined with air cells, foam or gel
components.
• Pros and cons same as fiberglass splints
Cramer Wire
Splint
• Ladder splint.
• Used for temporary splintage of fractures during
transportation.
• Made of 2 thick parallel wires with interlacing wires.
• Can be bent into different shapes.
THOMAS
SPLINT
• Devised by H.O Thomas initially for T.B Knee
Air Splints
• An air splint is used to immobilize a fracture using
an inflatable support.
• This type of splint is not generally used for long-term
support of a fracture as it is less secure and provides less
structural support than plaster splints or fiberglass splints.
INJURY ASSESSMENT/PRESPLINTING
PROCEDURE
• Have relevant important patient history
• Perform complete neurovascular assessment ?

• wounds should be appropriately covered with a sterile dressing.

- secured with the use of a rolled gauze.
• For acute fractures, immobilize the joint above (proximal) and below
(distal) the fracture when possible.

• Gather all supplies necessary for completion of the splint.

- Have more supplies than necessary rather than not have enough. Why ?

• Explain the treatment to the patient so he or she will have a thorough

understanding of the splinting procedure.
SPLINTING PROCEDURE
IF CAST PADDING IS USED:
• Select appropriate sized cast padding

• The cast padding should start distally and proceed proximally.

• Overlap the first circumference by 100%,. WHY ?????????

• An overlap of 50% should be used to cover the extremity

• Apply cast padding should be slightly angled WHY ?????????

• Proximal and distal ends should overlap 100 % for 3 circumferences .WHY ??

• Ensure boney prominences are well padded . WHY ????

SPLINTING PROCEDURE cont’
2. WATER
- cool or room-temperature water
- saturating fiberglass, plaster, or prefabricated splinting material.

- NEVER use hot or warm water!

- speeds the setting time
- creates a more exotherm reaction that can burn the patient.

Cooler water:
- slows the setting time
- increases sthe working time

NEVER REUSE THE SAME WATER . why

SPLINTING PROCEDURE cont’
3. Patient protection and comfort:
- use drape
- ensure patient is comfortable
4. Patient position
- directly in front of the technician during the procedure.
WHY??

5. Exotherm :
-pre-inform the patient and explain why it happens
SPLINTING PROCEDURE cont’
6. Molding and Securing the Splint
- molded to the body in order to maximize strength and increase the patient’s
comfort.

- Splints should be secured with compression bandage

- compression bandages NOT wrapped too tightly, WHY ?

- Do not rest a fresh splint on a pillow or exam table

 trapes exotherm and potentially burn the patient.

- wait until the exotherm has subsided before allowing the patient to leave.
SPLINTING PROCEDURE cont’
7.Post-splinting Checks
evaluate the patient’s F.A.C.T.S
• Function of non casted joint on injured part

• Arterial pulsations

• Capillary refill

• Temperature

• Sensations
PATIENT INSTRUCTION
8. Advice patient on danger signs of possible
compartment syndrome ( some of the 6Ps)

- Progressive Pain out of proportion

- Increased pressure/tightness
- Paresthesia ( burning, tingling/pricking )
- Excessive swelling below splint
- Avoid placing objects into the splint
- Avoid getting the splint wet
CASTING
• CASTING : Non operative management procedure for skeletal and or soft tissue
injuries in which a hard circular dressing with soft padding inside of it used to
immobilize body parts

• PURPOSE OF CASTING
• Provide immobilization
• Protect the injury
• Prevent further injury
• Decrease pain
• Allows soft tissues to settle and heal
SELECTION OF CAST
SUPPLIES
• The width of the cast tape and cast padding is generally determined by the

 width of the patient’s hand (upper extremity) and foot (lower extremity).

Pediatric patients generally need smaller sized materials (1-in. to 2-in. cast padding
and cast tape)

Adult patients need larger sized materials (3-in. to 4-in. cast padding and cast
tape).
PRECASTING CASTING
PROCEDURE
• Take relevant patient history

• Perform complete neurovascular assessment ?

• wounds should be appropriately covered with a sterile dressing.

- secured with the use of a rolled gauze.
• For acute fractures, immobilize the joint above (proximal) and below (distal) the
fracture when possible.

• Gather all supplies necessary for completion of the splint.

- Have more supplies than necessary rather than not have enough. Why ?

• Explain the treatment to the patient so he or she will have a thorough understanding
of the splinting procedure.
PRECASTING CASTING
PROCEDURE
1. Stockinette:
- Cut it longer that the cast . WHY ?
- Smoothen all wrinkles
- Be fit on the skin but not tight

2. Cast padding
PRECASTING CASTING
PROCEDURE
• Select appropriate sized cast padding

• The cast padding should start distally and proceed proximally. Why ?

• Overlap the first circumference by 100%,. WHY ?????????

• An overlap of 50% should be used to cover the extremity why ?

• Apply cast padding should be slightly angled WHY ?????????

• Proximal and distal ends should overlap 100 % for 3 circumferences .WHY ??

• Ensure boney prominences are well padded . WHY ????

CASTING PROCEDURE
1. Water
2. Patient comfort and protection
3. Patient position
4. Inform patient about exotherm
5. Casting : type varies according to injury type
6. Cast tape – same manner aptxn as cast padding
- submerge at 45deg for 3-5sec
 Position of
Immobilization
• Elbow: 90º of flexion
• Wrist: 30º of extension
• Thumb: midway between
maximal radial and palmar
abduction
• Hand: intrinsic plus (MCP joints
in at least 70º of flexion and IP
joints in extension)
– Position of Safe Immobilization
(POSI)
 The Hand
Position of Safe Immobilization
• (POSI)
Wrist: Moderate extension
• (10-45º)
• MCP joints: Flexion (70-90º)
PIP joints: Neutral
– The exact degrees can vary
slightly depending on
• reason for splinting
• conditions of the patient’s hand
(e.g. injury, surgery, existing
problems)
 The Hand
Position of Safe Immobilization
• MCP Flexion (POSI)
– Collateral ligaments are stretched and
tight
– Greater bone surface area contact
causing more joint stability
• MCP Extension
– Collateral ligaments are lax and
loose
– Less bone surface contact causing less
joint stability
CASTING PROCEDURE cont’
7. ROLLING
- Roll casts evenly for uniform strength,
- “ Rub it like you love it” should be your motto! Because :
1.it gives the cast its greatest strength,
2.makes it look good/ professionally casted,
3.eliminates wrinkles that can cause pressure sores

For upper extremity casts,

- keep the cast narrow in the web space between the thumb and index finger.
- Keep the palmar crease free to allow for good motion of the fingers.
CASTING PROCEDURE cont’
• Molding
 Cast should be well molded to the body in order to :
1. maximize strength
2. increase the patient’s comfort.

GUIDING BASIC PRINCIPLES OF MOLDING OF CAST

DOs
 Be patient when molding.
 Hold and mold.
 Use the palms and heel of your hands to mold,
 Use 3-point fixation to mold displaced fractures in long bones.
MOLDING CONT’
DONTs

Don’t keep squeezing and letting go

Don’t use fingers for molding

THE PRINCIPLE OF 3-POINT
FIXATION
3-point fixation :
is a manual molding technique of casts and splints which
can be used to obtain and maintain reduction of some
displaced fractures.

TECHNIQUE
1.Place one hand on the apex of the fracture,

2.Place your other hand on the opposite side distal to the

apex

3.Bring them together to align the fracture fragments.

 3-POINT FIXATION PRINCIPLE
cont,

4. Apple the initial layers of the cast or splint

5. Perform the same maneuver on the setting plaster or

fiberglass
- mold the fracture fragments in place within the cast
or splint.

This will help to limit the chances of the fracture

slipping out of place and losing the reduction
WHAT ARE YOUR OBSERVATIONS ABOUT THIS ?
POST CASTING EVALUATION
Post-casting Checks
evaluate the patient’s F.A.C.T.S

• Function of non casted joint on injured part

• Arterial pulsations

• Capillary refill

• Temperature

• Sensations
PATIENT INSTRUCTION POST
CASTING
Advice patient on danger signs of possible compartment syndrome
( some of the 6Ps)

Instruct to report to the ER IF any of the ff.

- Progressive Pain out of proportion

- Increased pressure/tightness

- Paresthesia ( burning, tingling/pricking )

- Excessive swelling below splint

PATIENT INSTRUCTION
CONT
- Avoid placing objects into the splint

- Avoid getting the splint wet

• Avoid walking or bearing weight on the cast until

told to do so
CAST REMOVAL
When removing or splitting casts,

 an electric cast saw or cast cutter is used.

 cast saw blade does not move in full circular revolutions.

 The blade on the saw oscillates, or moves back and forth

 cut along the cast in an “up and down” or an “in and out” motion, progressively
extending the initial cut into a straight line

 Demonstrating this may ease the apprehension of nervous patients.

CAST REMOVAL CONTINUE
• To facilitate the “in and out” motion,

• use the thumb or index finger to stabilize the hand and saw on the cast

• cut “in” the cast and use the thumb/finger as a counter force to lift “out.”

• Zip stick can be placed to ease patients apprehension

CAST REMOVAL TOOLS
INDEX FINGER
STABILIZATION TECHNIQUE
STABILIZTION TECHNIQUE:
THUMB
CAST REMOVAL STEPS
1. Position your patient

2. Prepare your patient and earn his/her trust.

3. Inspect the cast.

4. strategically plan your cuts

5. Stabilize the cast and begin cutting

6. Release the cast – cast spreader / scissors

Cast spreader
CAST REMOVAL
SPECIFIC CAST CUTTING
PROCEDURES
• Mono-valve/ Uni-valve
indication:
- to prevent or relieve circulatory restriction
-swelling present or anticipated

Spread cast end apart after valving

MONOVALVED CAST
SPECIFIC CAST CUTTING
PROCEDURES
• Bivalve : Indications:
1.Immediate removal when
- cast is too loose, dirty, broken, has lost its fracture reduction, evaluation of
fracture healing

2. Immediate removal to relieve circulatory constriction or compartment syndrome.

 Better to loose a fracture reduction than loose a limb
 Do N.V assessment using the 7ps and report to attending physician

3. Immediate removal to convert a cast into a night splint.

 Cast
Spreading
• Plaster cast:
– Cutting and spreading (univalving) reduce pressure by
40-60%

– Release of padding may reduce pressure an additional

10-20%.
 Cast
Spreading
• Fiberglass cast:
– Fiberglass casts have to be bivalved to
see similar decreases in pressure.
– In casts applied with the stretch-
relaxation method, univalving may be
sufficient as long as the cast can be
spread and held open.
– It is wise to use plastic cast wedges to
help hold open these split casts.
• Synthetic casts tend to spring back to their
original position after simply cutting one
side of the cast.
BIVALVED CAST
 WINDOWING A CAST
• Indications
• Wound care
• Investigating a complaint like a pressure sore
• Checking a pulse
• Breathing window in a body cast
• Ultrasound bone stimulator
WINDOW cont'
• When applying a cast over a wound that will need a window:

apply extra 4 x 4 gauze sponges in a stack over the wound to be

windowed.

Window after setting / no Exotherm

Mark edges of window

Cut slightly larger than the 4x4 gauze sponges

• Return rigid window cover to prevent window oedema

 WEDGING OF CASTS
• WEDGING (2 types ) – open /closed - discuss
• Indication
 correct for unwanted angulation of long bones, joints, or the spine.

• Always DO a check X- RAY

WEDGING OF CAST
TRIMMING OF CASTS
• INDICATION :
 Casts are trimmed when;
-their edges are too long and/or unpadded.

 Commonly done at the popliteal area. Why ?

 Mark trimming site 2in below the popliteal crease

 Ensure adequate padding of the trimmed end. why ?

CAST CONVERSION
• Indication
 when a long arm cast is cut down into a short arm cast
 Need for ROM at the elbow and forearm but protecting wrist fracture

• Long leg casts can also be converted into short leg casts
CAST CONVERSION CONT’
To make an accurate cut:
1. wrap a piece of string or a tape measure around the cast at the level where the
cast should be cut
2. mark it with a pencil, and then cut around the mark.
3. Bivalve the proximal portion to be removed and take it off.
4. Trim the remaining padding and stockinette so it is about two inches from the
edge of the short arm cast.
5. Flip this padding over the edge and secure it with tape, or casting material.
6. If the cast padding on the edge needs to be replaced, then a “petaling”
procedure needs to be done.
PETALING PROCEDURE
STEPS FOR PETALING
1. Position patient such that you can wrap cast padding around the proximal part of the cast.

2. Wrap three or four layers of cast padding around the proximal edge
such that half of the padding is on the cast and half of the padding goes over the edge onto
the skin.

3. Fold the cast padding that is on the skin so it is now tucked inside the cast and is padding
the edge.

4. Use a tongue depressor for tucking the padding inside the cast if your fingers are too big.

5. Add more layers if necessary to make it fit snug.

6. Finish the petaling by overwrapping the cast padding outside the cast with tape, or more
fiberglass/plaster.
 Duration of
Immobilization
• Excessive length of immobilization may lead to
problems such as joint stiffness, muscle atrophy,
cartilage degradation, ligament weakening, and
osteoporosis.
• This must be weighed against the bony healing
gained in prolonged immobilization.
 How do I take care of the
splint?
•Do not get the splint wet. Use plastic bags to
cover the splint while bathing.

• Do not walk on the splint.

•Do not stick anything down the splint Such as a

coat hanger to scratch or itch. This may lead to
injury and infection.
What danger signs should to look
for?
•Numbness, tingling, increased pain, change
in coloration of fingers or toes, or swelling
in fingers or toes.

•If these symptoms occur, you should call

your doctor immediately
 Complications
• Burns • Pressure sores
- Thermal injury as plaster dries Smooth Webril and plaster well
- Hot water, Increased number of
layers, extra fast-drying , poor • Infection
padding all increase risk - Clean, debride and dress all
- If significant pain - remove splint to wounds before splint application
cool - Recheck if significant wound or
increasing pain
• Ischemia
- Reduced risk compared to casting
but still a possibility
- Do not apply Webril and ace wra ps
tightly
- Instruct to ice and elevate extremi ty
- Close follow up if high risk for
swelling, ischemia.
- When in doubt, cut it off and look
Remember - pulses lost late.
 Thermal
Injury
• Contributing Factors:
– Speed of reaction
– Amount of reactants
– Temperature of the system (dip water and/or ambient
temperature): >50°C is too hot
– Thicker casts
• Those who are unfamiliar with the amount (ply) of plaster to
use may inadvertently use too much, resulting in a burn.
 Thermal
Injury
• Temperatures high enough to cause significant thermal
injury can be reached when the clinician places a curing
cast on a pillow.
• Reinforcing a curing plaster cast with fiberglass may place
the limb at significant risk.
– The synthetic overlap prevents heat from effectively dissipating.
•
Wait for the plaster to cure before either setting the
casted limb on a support frame or pillow or applying
fiberglass reinforcement.
 High-Risk Patients
• Patients with an • Temporarily place the limb in
inability to splint.
effectively • Splint can be removed to inspect
communicate: limb periodically.
• Such patients are at risk for
– Obtunded or
swelling (fluid shifts, bleeding,..).
comatose
polytrauma
patients
 High-Risk
Patients
• Patients under general or limb block anesthesia
(eg, axillary nerve, Bier)
– Unable to feel and respond to noxious stimuli (e.g. heat
and pressure) during cast application.
 High-Risk
Patients
• Very young or developmentally delayed patient
– Difficulty to clearly express pain.
– Almost any intervention can cause these patients to
become irritable. Thus, discerning a problem may be
difficult.
 High-Risk Patients
• Temporary splint.
• •Patient with
– Can be removed periodically to inspect
impaired limb.
sensation • Limit the length of immobilization
– Patients with spinal
– To combat the cycle of immobilization-
cord injury, induced osteopenia in the neuropathic
meningomyelocele, patient.
and systemic
– Patient may begin weight bearing while
disorders (eg, DM).
immobilized or be placed in flexible
– Vicious Circle: synthetic cast material that maintains
• Prolonged semirigid reduction.
immobilization
• → potentiation of
existing osteopenia →
increasing risk of
insufficiency fracture
→ further
immobilization
 High-Risk
Patients
• Patient with spasticity
– Spasticity + multiple risk factors (e.g. communication
difficulties and poor nutrition)
– These place the patient at particular risk for
developing pressure sores, which result from
increased tone after the cast is applied.
 “There are no hypochondriacs in
casts”
• Every patient complaint regarding the cast should be
evaluated in a timely manner by a member of the medical
team.
• Most limbs are more comfortable after immediate
immobilization.
– Increased pain and neurovascular change should be fully
evaluated.
•
Soft-tissue swelling, which may or may not have been
present during cast application, may lead to compartment
syndrome.
THANKS