Casts for scoliosis are now rarely used  because modern instrumentation. The technique is as follows

• Place the patient on a Risser table and apply a stockinette to extend from over the head to the knees.
• Position the removable crossbar at the level of the upper portion of the shoulders. Use felt to pad the canvas strap on which the patient is resting.
• Pass muslin straps around the waist over the stockinette and tie them at the level of the greater trochanter on the opposite side. Then pass the straps through the windlass at the end of the table and apply a slight amount of traction.
• Pad the iliac crest with felt.
• Use extra-strong, resin-reinforced plaster and extend the cast to the sternum anteriorly and the upper portion of the back posteriorly.
• Mold the cast well around the pelvis and iliac crest.
•  As the cast dries, trim it at the level of the pubic symphysis anteriorly, extending proximally to about the level of the anterior superior iliac spine to allow 100 degrees of hip flexion. Posteriorly, trim low over the buttocks at the level of the greater trochanters. Then trim proximally to relieve pressure over the sacral prominence.
•  Remove an abdominal window to free the upper portion of the abdomen, the lower costal margin, and the xiphoid process.

Canale & Beaty: Campbell's Operative Orthopaedics, 11th ed.

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Above Knee Plaster of Paris Cast

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An Example of Below Elbow Plaster Splint

Below elbow splint is commonly applied for many injuries of forearm and wrist. Theextent of this splint is from just below the olecronon tip to level of knuckles on the posterior aspect and 3-5 cm below flexion crease of elbow  to level of mid palmar creas eon the volar aspect.

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Early success led to the development of an orthosis similar in design that permitted freedom of motion of the ankle and knee joint. The system was expanded to include some diaphyseal fractures of the femoral shaft and fractures of the upper limbs following the success in tibial fractures.

The principle of the treatment by fracture bracing is to allow early mobilization with help of a brace that does not hamper function after the fracture has started glueing.  The initial cast is removed within two weeks and the limb is put in functional brace.

Trqaditional casting method had been to immobilize the limb one joint above and one below the fracture whereas functional bracing method devised the braces that would allow motion on on either side. This allowed early mobilization of the patient and early use of limb which aided into union of fracture.

Bracing is a philosophy of fracture care based on the idea that function and motion at the fracture site are conducive to osteogenesis.

The acceptibility range of fracture fragment was quite wide and higher degree of angulation and malposition was acceptable as long aas fracture united and it did not hamper the function or increased risk for late degenrative changes.

Here is what Sarmiento said on this

The use of fracture bracing often calls for the acceptance of a deviation from the normal anatomy of the fractured bone, but with the realization that minor changes in length, rotation, and alignment of long bones are easily compensated for and do not represent functional or cosmetic disturbances.

Functional bracing is best applied tosimple,  low-energy fractures. Other methods of treatment such as external fixation and closed intramedullary nailing have become the preferred treatment for many complicated fractures.

In the case of the tibial fracture, functional bracing continues to provide good results for closed low-energy fractures, particularly those with associated fibular fractures, though there is increased trend towards surgery due to increased patient demand for early activity.

The most common reason for complications with functional bracing is the lack of awareness of the ba¬sic physiologic foundations of the treatment and the belief that bracing is only a technique.

With time and more undrestanding of the subject, functional bracing indications have been defined better. It has been found that braces are helpful only in controlling angular deformities and do not prevent the shortening.

For example a comminuted fracture of tibia would not be served any good by brace as it would result in unaccpetable shortening.

Functional fracture bracing should not be used at the time of the initial treatment of acute fractures and should be introduced only after the acute symptoms have subsided. A brace should be discontinued and other therapeutic modalities introduced if the brace fails to provide or maintain the desirable stabilization and alignment of the fracture fragments.

Its success seems to be determined by an understanding of its philosophy and principles and by rigid adherence to the technical details, Srmiento observed

No related posts.

Most cases involve young adults with more than half of these cases have patients with scoliosis or kyphosis or treatment of hip condtions.  It has been seen after casting with body jackets, shoulder spicas, and hip spicas where the common denominator is exten¬sive coverage of the abdomen and chest.

The problem usually is located at the junction of the third and fourth parts of the duodenum, where the duodenum is bound by the ligament of Treitz. The duodenum passes across the anterior aspect of the lumbar spine from right to left at the level of the first and second lumbar vertebrae. Just above this point, the superior mesenteric artery arises from the abdominal aorta and passes downward with its ac¬companying veins in the mesentery.

Compression of Duodenum By Superior Mesentric Artery

There is the potential for compression of the third portion of the duodenum between lumbar spine and aorta posteriorly and the mesentery and vessels anteriorly.

Two contributing factors are recumbency, which causes the weight of the mesentery to lie against the duodenum, and increased lumbar lordosis, which tends to displace the duodenum anteriorly.

Gastric distention may aggravate the situation by forcing the remainder of the abdominal contents more distally and stretching the mesenteric vessels further.

Clinical Presentation

The signs and symptoms of cast syndrome are typical of upper intestinal obstruction. They may come on insidiously or after  several weeks after cast application or surgery.

The initial symptom is a feeling of fullness followed by nausea and vomiting.

Abdominal  distention is obscured in the presence of a body jacket. Vomiting, which may be intermittent in the early stages, becomes pernicious, with dehydration and metabolic alkalosis. Progressive metabolic derangement, oliguria, and shock may occur.

When these signs and symptoms occur in a patient who is in a body cast or who has had spinal trauma (including surgery), the diagnosis should be suspected.

Xrays of the abdomen may show early gastric dilatation.  Contrast may help to reveal the distention of the stomach and the proximal portion of the duodenum. Usualy there is a  sharp cutoff pattern at the region where the arteriomesenteric pedicle crosses the duodenum.  Xrays help to differentiate this syndrome from cholelithiasis, pancreatitis, gastric or duodenal ulcer, and high intestinal obstruction.

Prevention
Cast syndrome may be prevented by avoiding con-strictive body casts that accentuate lumbar lordosis or prevent normal changes in abdominal contour. Patients at risk should be turned frequently or encouraged to move themselves from side to side.

Treatment

• Removal of the offending plaster if any
• Absolute dietary restriction should be imposed, supplemented by nasogastric suction.
• Intravenous fluids are essential to maintain hydration and to correct any electrolyte or acid-base abnormalities.
• Positioning the patient on the left side or prone relieves some of the effects of gravity in pulling the mesenteric pedicle against the duodenum. With the patient prone, tipping the bed to tilt the head down further decreases pressure from the pedicle.
• If these conservative measures are not sufficient to reverse the process, the treatment of choice is surgery duodenojejunostomy or gastrojejunostomy.

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The picture in example is of leg of 18 years old boy who had been treated for fracture tibia with plaster cast application. When plaster was opened after two weeks for relentless pain in the limb.

The patient’s limb was kept on Bohler Braun splint and put on calcaneal pin traction.

The fracture healed uneventfully.

Note: Plaster sore is a common complication of the plaster cast application. To minimize the complication, the plaster should be well applied and patient should be instructed to report immediately for any severe pain.

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Plaster of Paris takes its name from Paris, France, where it was first widely used chemically, surgically and constructionally. However, one of the earliest surgical uses was recorded in 1852 when A. Mathyson, a Dutch Army Surgeon, rubbed powdered plaster into cotton bandages to form splints.

Plaster of Paris, in its raw state, is termed gypsum hydrated calcium sulphate with impurities. The surgical form is pure anhydrous calcium sulphate. The essential chemical step is the heating of gypsum to 120 degree Celsius (250 degree F).

Adding water allows for a return to the original crystalline state of full hydration. Twenty percent of added water is incorporated into the hydrated crystal lattice but the other 80 percent of water eventually evaporates.

The absorption of water while setting gives out heat (an exothermic reaction) but not enough to cause discomfort or injury.

Advantages

Plaster of Paris extremely safe and does not produce allergies. It is infinitely adaptable to the part being splinted and can be applied speedily without gloves. It cheap in comparison with more modern materials.

Disadvantages

Plaster of Paris is slow to dry, to gain full strength and is seriously weakened if it becomes wet again. It is very heavy when wet but becomes much lighter when dry. It is partially radio-opaque, obscuring bone detail on radiographs.

Mechanical Characteristics

Low temperatures and sugar solutions retard setting while high temperatures and salt or borax solutions accelerate it. The setting time is three times longer at 5 degree Celsius (40 degree F) than at 50 degree Celsius (125 degree F).

Although setting takes only a few minutes, drying may take many hours – roughly 36 hours for an arm cast, 48-60 hours for a leg cast and up to 7 days for a hip spica, especially if the atmosphere is moist and cool. Movement of the plaster while it is setting will cause gross weakening.

The optimum strength is achieved when it is completely dry (but as mentioned there is still a water content of 20 percent within the crystalline structure). Mechanical failure of a cast is due to the different elastic moduli in gauze fibres and hydrated calcium sulphate.

Alternatives to Plaster of Paris

Fibreglass and resinous materials can be safely applied as external splints. These are light, durable and waterproof but require protective packaging and are difficult to apply without wearing gloves.

They are considerably more expensive than plaster at present, but to balance this disadvantage, fewer bandages are required and they are much more durable and so are particularly suitable for active or elderly patients. They are more radiolucent than plaster.

A number of preformed plastic components are available as an alternative to plaster. They are made to fit different sizes of limbs and to allow movement at joints.

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Plaster cast removal is a procedure in itself. The procedure involves risk of injury to patient and should be done with utmost care. Following equipments are necessary for removing a cast

• Scissors
• Benders
• Electric cutter
• Materials for washing limb
• Supportive bandages or appliances

• The limb in plaster should be supported by sandbags. As most casts are removed by bivalving down the lateral sides these areas should be easily accessible.

• The choice of apparatus depends on several factors. Unpadded and skin-tight casts are cut with plaster shears. Completely padded casts can be cut with an electric plaster cutter.

The noise of the electric cutter frightens some children, and so shears may be used.

• The procedure is explained to the patient, and the apparatus that you will be using should be demonstrated to make them feel at ease.
• The cast should be cut steadily and smoothly. it is good to converse with patient to divert his focus.

Cutting Plaster With Plaster Shears

The size of shears used depends on the size of the cast. Draw guidelines down the side of the cast making sure that the line does not run directly over any bony prominences.

The stockinette is snipped at the ends of the cast to allow the shears to be positioned above this lining materials. If stockinette has not been used, try to insert the blade between the plaster and the padding wool.

Insert the blade under the plaster, parallel to the skin with the handle held steadily in the vertical position. The other blade cuts through the cast from above, its handle should be parallel to the cutting line at rest. This is the starting position, and if the blades are incorrectly aligned, the lower blade will press into the flesh causing bruises or even lacerations.

After each cut the blades should be realigned before the next cut is made. This prevents the skin wrinkling in front of the shears.These manoeuvers are important because the thick tips of the blades can press uncomfortably on the surface of the skin.

Remove the shears after every four or six cuts. Clear any clogging in the blades and use the plaster benders to open out the cast.

Never try to cut round corners. Always remove the blades and cut from the opposite end of the line to meet the end of the cut already made.

When using shears, keep the elbows relatively still and apply the cutting force from the shoulder girdle and chest muscles. This gives a more controlled power and saves energy.

The use of the electric plaster cutter

The electric cutter must only be used to cut completely padded casts.

Warning: If blood has impregnated the padding, it will be hard. Skin could adhere to it and the blades may cut directly into the skin.

When using an electric cutter make sure that:
• No strain is put on the cable, and enough cable is available for the operation in hand.
• The cable does not come near the cutting blade.
• Some older types of cutters should not be used in the presence of oxygen or inflammable gasses.
• The operator’s hands are dry.
• The apparatus is serviced regularly.

Position the patient correctly, and mark the line of cutting. Reassure the patient by showing them that the cutting blade works by oscillation, and only cuts hard materials. The blade becomes hot when used and cutting must be stopped if the patient feels any scorching. Start cutting with reduced pressure after examining the area involved. Position the blade at the start of the guideline, apply gentle pressure and move the cutter smoothly along the line. When cutting starts, there is a tendency to grip the cutter which exerts unwanted pressure on the cast. A new operator should be trained to reduce the pressure by continuous but gentle wrist movements.

The electric cutter should always be used carefully especially near bony prominences such as the medial border of the foot leading to the big toe.

Care of the part released from the cast

The cast may have to be bivalved for inspection, X-ray purposes and sometimes for skin preparation prior to operation. In these circumstances, the halves are replaced and held by a bandage until further direction is given.

On removal of the parts of the cast, support the limb between sandbags and closely inspect if for any signs of trauma inflicted during the removal procedure.

Wash and dry the part.

Gentle massage with oil, or cream, may help to restore normal nutrition and elasticity to the skin. After extended period of immobility some oedema is likely initially if the part is dependent. Elastocrepe or other supporting bandage may be needed.

These should support the whole area released from the cast. The new support should be applied at once and in the case of upper and lower limbs the patient should be advised to resume normal activity gradually, and to rest the part at regular intervals while maintaining digital exercises when at rest.

When a plaster is removed before surgery, skin texture and nutrition should be improved by massage. This can help to stimulate good wound healing after elective surgery.

Patients should always be warned that they may be incapacitated without the cast for the first few days until the muscles have regained their tone.

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Apart from immediate complications and plaster sores there are many other problems that can arise with plaster application.

Loss of Position

Because swelling occur with most fractures especially after reduction, the technician puts padding under the cast to protect the skin. This padding gets compressed. After 48 hours when the oedema is subsiding, the cast may be too loose to hold the bone ends in position against undesirable muscle action.

Such displacement may be sudden and cause pain or gradual being first noticed on the next x-ray. This complication may seriously delay sound healing and may produce permanent deformity. Medical advice must be sought if the position is suspect.

Nerve Damage

Loss of power, tingling and numbness distal to the cast are signs of impaired nerve function. The cause may be direct compression by bone ends or plaster pressure, indirect compression of oedematous tissue or tourniquet effect, or reduced blood flow.

Routine testing of power and sensation will detect any defect quickly. Corrective action includes relieving cast pressure, supporting and protecting paralyzed parts, and physiotherapy to help restore normal function of muscle and joints.

Local Complications

Encasement of the limb or trunk in plaster may produce stiff joints, muscle wasting and impaired circulation. Physiotherapy and good nursing can help reduce these complications and speed the final recovery.

Systemic Complication

The most serious is deep venous thrombosis leading to pulmonary embolism. Pain in the calf is an important sign needing medical advice.

Immobilisation in trunk plasters or plaster beds may also produce nausea, abdominal muscle cramps, retention of urine and abdominal distention.

Good nursing and diet with regular exercises will help ensure that the initial period of extensive immobilization is achieved without complications.

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Development of plaster sore is very painful. It is a constantly nagging pain that does not leave the patient.The patient is often able to pinpoint the sore area. If patient complains of unrelenting pain or digging sensation the part should be examined.

It should not be ignored at any cost otherwise the results could be disastrous consequences.

A window is cut in the plaster, with an electric cutter. Then underlying padding and lining is removed to inspect the skin.

The skin is examined for any redness or wound.

Sores are graded according to depth of the involvement.

• Grade I-Redness of skin

• Grade II-Involvement of Subcutaneous Tissue or Cellulitis

• Grade III- Involvement of Muscles

• Grade IV- Bone Deep

The treatment of sore depends upon the grade. While grade I only requires removal of offending pressure others require treatment that varies from simple dressings to surgical debridement and reconstructive procedures.

The fracture needs to be splinted throughout. In some cases it might be pertinent to shift to external fixation of the fracture.

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3. Complications Associated With Plaster Application