Definition

A cast is a rigid dressing used to immobilize a fractured bone or soft tissue injury. It is made of
strips impregnated with plaster or fiberglass material. The injured area is first covered with a
layer of padding made of cotton or synthetic materials to protect the skin from irritation. The
plaster or fiberglass strips are then dipped in water and applied over the padding to form the cast.

Purpose
In general, casts are applied to injured limbs to support and protect the bones and soft tissue. The
cast helps to reduce the pain, swelling, and muscle spasms following the injury. If the bone is
broken, the cast holds the fractured bone ends in correct alignment during the healing process. A
cast, because of its rigid properties, will also provide protection from further injury. Body casts
are used to prevent movement of the vertebrae of the back and may be used after a traumatic
injury to the spine or a surgical repair of the vertebrae.

Precautions
For health professionals

Wet casts must be handled carefully, using only the palms of the hands, because a wet cast can
be dented or compressed if handled too much after application. Dents or compression of the cast
can cause pressure or irritation to the skin beneath the dressing, which may develop sores or
ulcers.

Patients in a hip cast or body cast should be repositioned every two hours during the first 24
hours to allow even drying of the cast and every two hours when awake thereafter to avoid
developing pressure sores on the skin.

For patients

The use of crutches may be recommended for patients with a leg cast or a sling for patients with
an arm cast for use during the first 24-48 hours. Patients should be instructed to rest and keep the
affected limb elevated on a pillow as much as possible during the first 24 hours.

Description
Materials

Of the two types of materials used for the hard supportive layer of cats, fiberglass has the
advantages of being lighter, longer-wearing, and better able to "breathe" than plaster. Fiberglass
is less trouble for the patient, because plaster casts are more likely to lose their shape if they
become wet than fiberglass casts. It is also easier for x rays to penetrate fiberglass than plaster
casts. Plaster, on the other hand, is less expensive and is easier to mold or shape to the body. A
plaster cast will harden in 15–30 minutes but takes 24–48 hours to dry completely. A fiberglass
cast will dry faster, in 15–30 minutes, but the force of the patient's full body weight may cause
the cast to crack in the first 24 hours after application.

Application

Casts are usually applied by physicians or orthpedic technicians, with the assistance of other
health professionals. If the bone is broken, the physician will first place the fractured bone into
alignment. Stockinette cut to size is applied to the limb and then cast padding (cotton batting) is
wrapped around the extremity. The physician dips the casting material in water, squeezes out
excess water, and then applies it wet over the cast padding to form the cast. After applying the
cast, the physician will roll the stockinette over the edges of the cast to provide smooth edges at
the top, bottom and any openings on the cast. The patient's toes and fingertips are not covered by
the cast. The cast is then usually placed on pillows elevated above the patient's heart level for
15–20 minutes to dry.

Preparation
A health professional will assist the patient in removing any clothing that will be difficult to pull
over the cast later. The patient is positioned with the affected extremity resting on a pillow. The
skin around the affected area is gently cleansed and thoroughly dried. The patient may be given
medication for pain as directed by the physician. After the cast has been applied, extra pillows
are placed under the cast to elevate it. The patient should be kept warm and comfortable while
the cast is drying. It is helpful to explain to the patient that the cast will feel warm at first but
then cool and damp as the material dries.

Aftercare
Aftercare includes measuring the patient for crutches or a sling as appropriate. In addition,
patients should be given aftercare instructions as follows:

 The cast should be kept dry. Water weakens plaster casts and may cause skin irritation
beneath the cast. The patient should use two layers of plastic to keep the cast dry while
bathing or showering.
 To decrease swelling and pain in the first 24–48 hours, the patient should place crushed
ice in a plastic bag, covered with a pillow case or towel, on the cast over the injury every
15 minutes per hour while awake.
 Dirt, sand, or powder should be kept away from the inside of the cast. Cast boots can be
purchased to cover the foot area of a leg cast.
 Padding should not be pulled out of the cast. In addition, the patient should not stick coat
hangers, knitting needles, or similar items inside the cast in order to scratch itchy skin.
 The patient should not break off or trim the edges of the cast without consulting the
physician.
 The cast should be inspected regularly. If it develops cracks or soft spots, the physician
should be notified.
  The patient should never attempt to remove the cast. The physician will remove the cast
at the appropriate time with a special saw that cuts through the casting material but will
not damage skin.

Complications
Compartment syndrome

A serious complication that can occur after cast application is known as compartment syndrome.
This is a rare phenomenon that occurs when a cast is too tight. As the affected limb swells, the
cast acts as a closed compartment, tightly compressing the nerves and blood vessels.
Compartment syndrome can cause permanent nerve damage or loss of limb due to decreased
circulation and oxygen to the tissue. Patients should be instructed to call the physician at once if
any of the following signs or symptoms appear:

 increased pain combined with the feeling that the cast is too tight
 numbness and tingling in the hand or foot
 burning and stinging sensations
 excessive swelling in the part of the limb below the cast
 inability to actively move the toes or fingers

Compromised healing

Another complication of cast application is that the injury may not heal properly. In some cases
the bone endings are set incorrectly, producing a deformity; or do not unite at all. Either may
require surgical correction. Delayed union of the bone endings may occur in elderly or
malnourished patients; their casts may need to remain in place for a longer period of time.

Results
Cast application is an effective treatment for a fractured bone, serious soft tissue injury or
surgical joint repair. Casts generally remain in place until bone healing occurs (four to six
weeks). The physician will order x rays to monitor bone healing. X rays can be done through the
cast. As bone healing occurs and the limb strengthens, the physician may replace the initial cast
with a shorter one or a splinted cast that can be removed for bathing. When the cast is removed,
the patient's skin will appear dry and the muscles of the limb may be slightly wasted. Skin care
with moisturizers and special exercises to regain muscle strength or to relieve joint stiffness may
be ordered by the physician.

Health care team roles

Cast application is usually performed by a physician but may be performed by a specially trained
orthopaedic technician under the direction of the physician. The licensed nurse will assess the
inpatient patient in a medical setting with a newly casted limb for the first 24-48 hours after cast
application. In the outpatient setting, the licensed nurse will observe the patient for the first hour
after cast application and instruct the patient and patients family about cast care, signs and
symptoms of complications and the importance of follow-up visits with the physician for routine
reassessment and cast removal.

KEY TERMS

Compartment syndrome—A potentially serious complication of cast application, caused by

pressure of the cast on the nerves and blood vessels in the injured limb.

CAST CARE OVERVIEW

You have been fitted with a cast or splint to protect your bone and reduce pain as you heal. It is
important to take care of your cast or splint to minimize the risk of potential complications, such
as skin infection. If you have questions or concerns about your cast, contact your healthcare
provider.

CAST CARE INSTRUCTIONS

 Mild swelling of the injured area is common during the first few days. Swelling may
make your cast feel tight initially. To reduce swelling, keep the cast above the level of
your heart for 24 to 48 hours. This can be accomplished by resting it on pillows. Also,
gently move your fingers or toes (where the cast is located) frequently.
 Ice helps keep the swelling down. Apply a bag of ice (or a bag of frozen vegetables)
covered with a thin towel to the cast for 20 minutes every two hours while awake. Do not
apply ice directly to the skin.
 Take your pain medicine if you have pain. After the first few days, you may be able to
take a non-prescription pain medication, such as ibuprofen (Advil, Motrin) or
acetaminophen (Tylenol and others).
 Do not get the cast or splint wet. To bathe with a cast, cover the cast with a plastic bag,
tape the opening shut, and hang the cast outside the tub. Even when covered with plastic,
you should not place the cast in water or allow water to run over the area. Waterproof
cast covers are available at medical supply stores, but are not completely waterproof.
 If the cast becomes wet, you can dry it with a hair dryer on the cool setting. Do not use
the warm or hot setting because this can burn the skin. You can also use a vacuum
cleaner with a hose attachment to pull air through the cast and speed drying.
  Keep the cast clean and avoid getting dirt or sand inside the cast. Do not apply powder or
lotion on or near the cast. Cover the cast when eating.
 Do not place anything inside the cast, even for itchy areas. Sticking items inside the cast
can injure the skin and lead to infection. Using a hair dryer on the cool setting may help
soothe itching.
 Do not pull the padding out from inside your cast.

WHEN TO SEEK HELP

 If there are sore areas or a foul odor from the cast, cracks or breaks in the cast, or the cast
feels too tight.
 You develop swelling that causes pain or makes it so you cannot move your fingers or
toes.
 You develop tingling or numbness in the arm or fingers or toes.
 Your fingers or toes are blue or cold.
 You develop severe pain in or near the casted arm or leg.
 The cast becomes soaking wet and does not dry with a hair dryer or vacuum

Cast Care
Cast Care Introduction

 The function of a cast is to rigidly protect an injured bone or joint. It serves to hold the
broken bone in proper alignment to prevent it from moving while it heals.

 Casts may also be used to help rest a bone or joint to relieve pain that is caused by
moving it (such as when a severe sprain occurs, but no broken bones).

 Different types of casts and splints are available, depending on the reason for the
immobilization and/or the type of fracture.
Casts are usually made of either plaster or fiberglass material.
Fracture Types and Healing

 A fractured bone is the same as a broken bone. Most fractures happen because of a single
and sudden injury. The diagnosis of a fracture is usually made with an x-ray film.

o A simple (or closed) fracture has intact skin over the broken bone.

o An open fracture is also called a compound fracture. This means that a cut or
wound exists on the skin near the broken bone. If the cut is very severe, the edges
of the bone may be seen coming out from the wound. 

o A stress fracture can result from many repeated small stresses on a bone.
Microscopic fractures form and, if not given time to heal, can join to form a stress
fracture. These types of fractures are usually seen in athletes or soldiers who
perform repetitive vigorous activities.

o A pathologic fracture happens with minimal or no injury to an abnormal bone.

This is usually caused by an underlying weakness or problem with the bone itself,
such as osteoporosis or tumor.

 When a bone is fractured, it may require a reduction or realignment to put the ends of the
fracture back into place. A doctor will do this by moving the fractured bone into
alignment with his or her hands. If a bone has a fracture but is not out of position or
deformed, no reduction is necessary.

 When the ends of the bone are aligned, the injured bone requires support and protection
while it heals. A cast or splint usually provides this support and protection.

 Many factors affect the rate at which a fracture heals and the amount of time a person
needs to wear a cast. Ask a doctor how much time the specific fracture will take to heal.
How Casts Are Applied

Many different sizes and shapes of casts are available depending on what body part needs to be
protected. A doctor decides which type and shape is best for each person.

 Cast application

o Before casting material is applied (plaster or fiberglass), a "stockinette" is usually

placed on the skin where the cast begins and ends (at the hand and near the elbow
for a wrist cast). This stockinette protects the skin from the casting material.

o After the stockinette is placed, soft cotton batting material (also called cast
padding or Webril) is rolled on. This cotton batting layer provides both additional
padding to protect the skin and elastic pressure to the fracture to aid in healing.

o Next, the plaster or fiberglass cast material is rolled on while it is still wet.

o The cast will usually begin to feel hard about 10-15 minutes after it is put on, but
it takes much longer to be fully dry and hard.

o Be especially careful with the cast for the first 1-2 days because it can easily crack
or break while it is drying and hardening. It can take up to 24-48 hours for the cast
to completely harden.

 Plaster casts

o A plaster cast is made from rolls or pieces of dry muslin that have starch or
dextrose and calcium sulfate added.

o When the plaster gets wet, a chemical reaction happens (between the water and
the calcium sulfate) that produces heat and eventually causes the plaster to set, or
get hard, when it dries.
 o A person can usually feel the cast getting warm on the skin from this chemical
reaction as it sets.

o The temperature of the water used to wet the plaster affects the rate at which the
cast sets. When colder water is used, it takes longer for the plaster to set, and a
smaller amount of heat is produced from the chemical reaction.

o Plaster casts are usually smooth and white.

 Fiberglass casts

o Fiberglass casts are also applied starting from a roll that gets wet.

o After the roll gets wet, it is rolled on to form the cast. Fiberglass casts also get
warm and harden as they dry.

o Fiberglass casts are rough on the outside and look like a weave when they dry.
Some fiberglass casts may even be colored.

Ice and Elevation

 A doctor may want the person to use ice to help decrease the swelling of the injured body
part. (Check with a physician before using ice.)

 To keep the cast from becoming wet, put ice inside a sealed plastic bag and place a towel
between the cast and the bag of ice.

 Apply ice to the injury for 15 minutes each hour (while awake) for the first 24-48 hours.
  Try to keep the cast and injured body part elevated above the level of the heart, especially
for the first 48 hours after the injury occurs.

 Elevation will help to decrease the swelling and pain at the site of the injury.

 Propping the cast up on several pillows may be necessary to help elevate the injured area,
especially while asleep.

Taking Care of Your Cast

 Always keep the cast clean and dry.

 If the cast becomes very loose as the swelling goes down, call the doctor for an
appointment, especially if the cast is rubbing against the skin.

 Cover the cast with a plastic bag or wrap the cast to bathe (and check the bag for holes
before using the bag a second time). Some drug stores or medical suppliers have cast
covers—plastic bags with Velcro straps to seal out water for protection during bathing.
Avoid showers; use the bathtub and hang the covered cast or injured body part outside of
the tub while you bathe. Do not lower the cast down into the water.

 If a fiberglass cast gets damp, dry it (make sure it dries completely). Because a fiberglass
cast allows air through it, a hairdryer on the cool setting should do the trick (do not try to
dry it using a hairdryer without a cool setting—you could burn yourself). If you have any
trouble getting the cast dry, call a doctor to find out if the cast needs to be replaced.

 If the cast gets wet enough that the skin gets wet under the cast, contact the doctor. If the
skin is wet for a long period of time, it may break down, and infection may occur.

 Sweating enough under the cast to make it damp may cause mold or mildew to develop.
Call the doctor if mold or mildew or any other odor comes from the cast.
  Do not lean on or push on the cast because it may break.

 Do not put anything inside the cast. Do not try to scratch the skin under the cast with any
sharp objects; it may break the skin under the cast. Do not put any powders or lotions
inside the cast.

 Do not trim the cast or break off any rough edges because this may weaken or break the
cast. If a fiberglass cast has a rough edge, use a metal file to smooth it. If rough
places irritate the skin, call the doctor for an adjustment.

 An arm sling may be needed for support if the cast is on the hand, wrist, arm, or elbow. It
is helpful to wrap a towel or cloth around the strap that goes behind the neck to protect
the skin on the neck from becoming sore and irritated.

 If the cast is on the foot or leg, do not walk on or put any weight on the injured leg,
unless the doctor allows it.

 If the doctor allows walking on the cast, be sure to wear the cast boot (if given one by the
doctor). The boot is to keep the cast from wearing out on the bottom and has a tread to
keep people in casts from falling.

 Crutches may be needed to walk if a cast is on the foot, ankle, or leg. Make sure the
crutches have been adjusted properly before leaving the hospital or the doctor's office.

How a Cast Is Removed

 Do not try to remove the cast.

  When it is time to remove the cast, the doctor will take it off with a cast saw and a special
tool.

o A cast saw is a specialized saw made just for taking off casts. It has a flat and
rounded metal blade that has teeth and vibrates back and forth at a high rate of
speed.

o The cast saw is made to vibrate and cut through the cast but not to cut the skin
underneath.

o After several cuts are made in the cast (usually along either side), it is then spread
and opened with a special tool to lift the cast off.

o The underlying layers of cast padding and stockinette are then cut off with
scissors.


 After a cast is removed, depending on how long the cast has been on, the underlying body
part may look different than the other uninjured side.

o The skin may be pale or a different shade.

o The pattern and length of hair growth may also be different.

o The injured part may even look smaller or thinner than the other side because
some of the muscles have weakened and have not been used since the cast was
put on.

o If the cast was over a joint, the joint is likely to be stiff. It will take some time and
patience before the joint regains its full range of motion.

Complications
Many potential complications are related not only to wearing a cast but also to the healing of the
underlying fracture.

Immediate complications

 Compartment syndrome

o Compartment syndrome is a very serious complication that can happen because of

a tight cast or a rigid cast that restricts severe swelling.

o Compartment syndrome happens when pressure builds within a closed space that
cannot be released. This elevated pressure can cause damage to the structures
inside that closed space or compartment—in this case, the muscles, nerves, blood
vessels, and other tissues under the cast.

o This syndrome can cause permanent and irreversible damage if it is not

discovered and corrected in time.

o Signs of compartment syndrome

 Severe pain

 Numbness or tingling

 Cold, pale, or blue-colored skin

 Difficulty moving the joint or fingers and toes below the affected area.
 
o If any of these symptoms occur, call the doctor right away. The cast may need to
be loosened or replaced.
 
 A pressure sore or cast sore can develop on the skin under the cast from excessive
pressure by a cast that is too tight or poorly fitted.
Delayed complications

 Healing problems

o Malunion: The fracture may heal incorrectly and leave a deformity in the bone at
the site of the break. (Union is the term used to describe the healing of a fracture.)

o Nonunion: The edges of the broken bone may not come together and heal
properly.

o Delayed union: The fracture may take longer to heal than is usual or expected for
a particular type of fracture.
 
 Children are at risk for a growth disturbance if their fracture goes through a growth plate.
The bone may not grow evenly, causing a deformity, or it may not grow any further,
causing one limb to be shorter than the other.

 Arthritis may eventually result from fractures that involve a joint. This happens because
joint surfaces are covered by cartilage, which does not heal as easily or as well as bone.
Cartilage may also be permanently damaged at the time of the original injury.

When to Call Your Doctor

 Check the cast and the skin around the edges of the cast everyday. Look for any damage
to the cast, or any red or sore areas on the skin.

 Call the doctor immediately if any of the following happen:

 The cast gets wet, damaged, or breaks.

 Skin or nails on the fingers or toes below the cast become discolored, such as blue
or gray.

 Skin, fingers, or toes below the cast are numb, tingling, or cold.
 The swelling is more than before the cast was put on.

 Bleeding, drainage, or bad smells come from the cast.

 Severe or new pain occurs.