Pros and Cons of Plaster and Splint application

Department of OrthopaedicsSri Venkateshwaraa Medical College and Research Center

• Fractures.• Sprains. • Severe soft tissue injuries.• Reduced joint dislocations.• Inflammatory conditions: arthritis,

tendinopathy, tenosynovitis.• Deep laceration repair across joints.• Tendon lacerations.

Advantages of Plaster application• Versatile, readily applied and fashioned.• Reasonably comfortable.• Absorbs secretions to some extent.• Fairly strong.• Radio translucent.• Immediate Stabilisation of fracture fragments and

prevent further soft tissue damage.• Non invasive procedure: Acceptance of patient is

good.• Cheap and easily available.

Indications

• In polytrauma, splinting causes temporary stabilisation of bone and soft tissue, aids in control of haemorrhage and helps reduce pain and prevent further injury.

• Fractures with minimal or no displacement merely require some type of external support or protection to prevent displacement.

• Displaced fractures with initially unacceptable position require some type of reduction to achieve acceptable alignment.

Indications

• Temporary Stabilisation of fracture till definitive procedure is done.

• Immobilisation following operative procedures• In highly communited fractures where operative

reduction is not possible.• In patients with other comorbidities which make

operative treatment not possible.• Osteoporotic fractures.• Paediatric fractures in acceptable position with

high potential for remodelling.

.

Complications of splint and cast • Heaviness and ease of water damage• Difficult to inspect the limb• Pressure sores• Burns • Dermatitis• Cast window Blisters• Muscle atrophy• Joint stiffness• Distal edema• Malpositioning/Displacement• Deep vein Thrombosis • Reflex sympathetic dystrophy• Compartment syndrome

Pressure sores

• Skin breakdown is the most common complication – Casts that are applied too tight with out proper

padding will lead to pressure sores over bony prominences

– Loosening and distal migration of casts will lead to friction and blisters

• Focal pressure from a wrinkled, unpadded, or underpadded area over a bony prominence or underlying soft tissue causes pressure sores.

• Can be minimized by ensuring that the padding is adequate and smooth, without indentations during application.

Burns

• Setting of plaster is an exothermic reaction• In patients with sensitive skin this exothermic

reaction can cause burns if not adequately padded.

• Factors – Speed of setting: faster more heat generation.– Thickness of plaster: more thickness more heat

generation– Increased temperature of dipping water

Dermatitis

• Allergic dermatitis.• Bacterial and fungal infections or a pruritic

dermatitis can develop beneath a splint or cast.

• Is more common with an open wound, but the moist, warm environment of a splint or cast can be ideal for infection.

Muscle Atrophy

Joint stiffnes

• The periarticular structures of human joint adaptively shorten under any circumstance in which the joint is not carried through the full range of motion.

• Exercise the joints that are not held in a cast as much as possible.

Distal Edema

• Due to decreased venous return.• Do not let the affected limb hang down unless

it is being used. Keep it elevated, especially during the first few days.

Malposition/Displacement

• With the resolution of initial fracture swelling, the extremity no longer fits well inside the cast. The forces required to maintain fracture position are diminished, and loss of reduction may ensue.

A cast that is too large for the current volume of the extremity needs to be changed to one that fits properly. Ignoring this fact because of a fear that the reduction will be lost if the cast is changed is irrational.

Deep vein thrombosis• Reduced rate of blood flow due to immobility of extermity.• Risk factors:– Previous DVT or pulmonary embolism (PE)– Trauma– Family history of DVT or PE.– Smoking– Obesity/overweight– Pregnancy.– Age over 40 years.– contraceptive pill or HRT which contain oestrogen.– Very large varicose veins– Recent medical illness

Compartment Syndrome

• Compartment syndrome is a potentially devastating entity that may develop when injury induces increased pressure within a closed space.

• Cast application causes decrease in compartment volume.

• It is a condition of increased pressure within a closed space that compromises blood flow and tissue perfusion and causes ischemia and potentially irreversible damage to the soft tissues within that space.

The best treatment of a compartment syndromeis avoidance.

• If an immobilized patient experiences worsening pain, tingling, numbness, or any sign of vascular compromise such as severe swelling, delayed capillary refill, or dusky appearance of exposed extremities, an immediate visit to the nearest emergency department is indicated for prompt removal of the cast.

Take home message

• Properly position the extremity before, during and after application of materials

• A well-applied cast has only two layers of cast padding on all areas except bony prominences, which require a third or fourth. A cast with too much padding will fail to hold a reduction, whereas one with too little may result in pressure sores.

• Once a cast has been applied it should be molded to provide three-point fixation of the fracture. Avoid excessive molding and indentations.

Take home message

• Avoid tension and wrinkles on padding, plaster, and fiberglass.

• Instruct patient should return if numbness, tingling, increased pain and impaired sensation

• Re-evaluate in 48 hours for neurovascular compromise 5 P’s : Pain, Pallor, Paresthesia, Pulselessness, and Paralysis.

• Orthopedic evaluation in 7-10 days for casting.

Thank You

Applying a well-molded cast or splint is an Acquired Skill.