Jeseo O.

Gorme, RN, MN
 A cast is a rigid external immobilizing device that is
molded to the contours of the body.
 Uses:
 Immobilize a fracture
 Correct a deformity
 Apply uniform pressure to underlying soft tissue
 Support and stabilize weakened joints
 Type:
 Short-arm cast: extends from below the elbow to the
palmar crease, secured around the base on the thumb. If
the thumb is included, it is known as thumb spica or
gauntlet cast.
 Long-arm cast: Extends from the axillary fold to the
proximal palmar crease. The elbow usually is
immobilized at a right angle.
 Short-leg cast: Extends from below the knee to the base
of the toes. The foot is flexed at a right angle in a neutral
position.
 Long-leg cast: Extends from the junction of the upper
and middle third of the thigh to the base of the toes. The
knee may be slightly flexed.
 Walking cast: A short- or long-leg cast reinforced for
strength.
 Body cast: Encircles the trunk.
 Shoulder spica cast: A body jacket that encloses the
trunk and the shoulder and elbow.
 Hip spica cast: Encloses the trunk and a lower extremity.
A double hip spica cast include both legs.
 Compartment Syndrome
 It occurs when there is decreased tissue perfusion within
a limited space that comprises the circulation and the
function of the tissue within the confined area.
 To relieve the pressure, the cast must be bivalved (cut
in half longitudinally) and the extremity must be
elevated no higher than heart level to ensure arterial
perfusion.
1. With a cast cutter, a longitudinal cut is made to divide
the cast in half.
2. The underpadding is cut with scissors.
3. The cast is spread apart with cast spreaders to relieve
pressure and to inspect and treat the skin without
interrupting the reduction and alignment of the bone.
4. After the pressure is relieved, the anterior and posterior
parts of the cast are secured together with an elastic
compression bandage to maintain immobilization.
5. To control swelling and promote circulation, the
extremity is elevated (but no higher than heart level, to
minimize the effect of gravity on perfusion of the tissues.
 Pressure Ulcers
 Lower extremity sites most susceptible to pressure ulcers
are the heel, malleoli, dorsum of the foot, head of the
fibula, and anterior surface of the patella.
 In the upper extremities, the main pressure sites are
located at the medial epicondyle of the humerous and
the ulnar styloid.
 The physician bivalve the cast, inspect and possibly treat
the area.
 The portion that was lost is replaced and held in place
by an elastic compression dressing or tape.
 Disuse Syndrome
 Muscle atrophy and decreased muscle strength might
result if the muscles within the cast are not used.
 Patients need to learn to tense or contract muscles
without moving the part (isometric muscle contraction).
 Teach the patient with a leg cast to “push down” the
knee and teach a patient with arm cast to make a fist.
 Isometric exercises should be performed hourly while
the patient is awake.
 Quadriceps-Setting Exercise
1. Position patient supine with leg extended.
2. Instruct patient to push knee back onto the mattress
by contracting the anterior thigh muscles.
3. Encourage patient to hold the position for 5-10
seconds.
4. Let patient relax.
5. Have the patient repeat the exercise 10 times each hour
when awake.
 Gluteal-Setting Exercise
1. Position the patient supine with legs extended, if
possible.
2. Instruct the patient to contract the muscles of the
buttocks.
3. Encourage the patient to hold the contraction for 5-10
seconds.
4. Let the patient relax.
5. Have the patient repeat the exercise 10 times each hour
when awake.
 Nonplaster
 Also referred to as fiberglass casts, are made from
water-activated polyurethane materials and have the
versatility of plaster but are lighter in weight, stronger,
water resistant, and durable.
 These materials are porous and therefore diminish skin
problems.
 When wet, they are dried with a hair dryer on a cool
setting.
 They are used for long term wear.
 Plaster
 Rolls of plaster bandage are wet in cool water and
applied smoothly to the body. A crystallizing reaction
occurs and heat is given off.
 The heat given off is uncomfortable, so the nurse should
inform the patient about the sensation of increasing
warmth so that the patient does not become alarmed.
 Additionally, the nurse should explain that the cast
needs to be exposed to the air to allow maximum
dissipation of the heat and that most casts cool after
about 15 minutes.
 While the cast is damp, it can be dented that is why it
must be handled with the palms of the hands and not
allowed to rest on hard surfaces or shard edges.
 The plaster cast requires 24-72 hours to dry completely,
depending on its thickness and the environmental
drying conditions.
 A dry plaster cast is white and shiny, resonant to
percussion, odorless, and firm.
 Provide frequent rest periods as necessary to avoid fatigue.
 Elevate the immobilized arm to control swelling.
 When the patient is lying down, the arm is elevated so that
each joint is positioned higher than the preceding proximal
joint (eg. Elbow higher than the shoulder, hand higher
than the elbow)

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 A sling may be used when the patient ambulates.
 The sling should distribute the supported weight over a
large area and not on the back of the neck to prevent
pressure on the cervical spine nerves.
 Circulatory disturbances in hand may become apparent
with signs of cyanosis, swelling, and an inability to move
the fingers.

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 One serious effect of impaired circulation in the arm is
Volkmann’s contracture.
 There is contracture of the fingers and wrist occurring as a
result of obstructed arterial blood flow to the forearm and
hand.
 The patient is unable to extend the fingers, describes
abnormal sensation (unrelenting pain), and exhibits signs
of diminished circulation to the hand. Permanent damage
may occur within a few hours if action is not taken.

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 In presence of swelling, the patient’s leg must be supported
on pillows to heart level to control swelling, and ice packs
should be applied as prescribed over the fracture site for 1
or 2 days.
 Assess circulation by observing the color, temperature, and
capillary refill of the exposed toes.
 Nerve function is assessed by observing the patient’s ability
to move the toes and by asking the sensation.

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 Monitor for cast syndrome which occurs as a result of
psychological (claustrophobia) and physiologic
(immobility) responses to confinement to a cast.
 Explain the procedure to the patient to remove any
apprehensions about being encased in a cast.
 The nurse reassures the patient that several people will
provide care during the application, that support for the
injured area will be adequate, and the care providers will be
as gentle as possible.

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 To protect the cast from soiling, insert clean dry
plastic sheeting under the dry cast and over the
cast edge before elimination of the patient.
 Inspect the skin around the edges of the cast
frequently for signs and symptoms of irritation.
 Turn the patient to a prone position, twice daily if
tolerated, to provide postural drainage of the
bronchial tree and to relieve pressure on the back.
Place a small pillow under the abdomen to
enhance to comfort. Put a pillow lengthwise under
the dorsa of the feet or allow the toes to hang over
the edge of the bed to prevent the toes from being
forced into the mattress.
 They are used to manage open fractures with soft
tissue damage.
 Indications include:
 Complicated fractures of the humerus, forearm, femur,
tibia, and pelvis.
 Prepare the patient psychologically for application
because the apparatus might look clumsy and foreign.
 Reassure that the discomfort associated with the
device is minimal and that early mobility is anticipated
to promote patient acceptance to the device.
 After the insertion, the extremity is elevated to reduce
swelling.
 If there are sharp points on the fixator, they are
covered with cork or tape to prevent device-induced
injuries.
 Carry out pin care which typically includes cleaning
each pin site separately one or two times daily with
cotton-tipped applicator soaked in chlorhexidine
solution.
 If signs of infection or clamps seem loose, report to the
physician immediately.
 Assist in isometric and active exercises as tolerated.
 NURSING ALERT!
The nurse never adjusts the clamps on the
external fixator frame. It is the physician’s
responsibility to do so.
 Traction is the application of a pulling force to a part of
the body.
 Indications:
 Minimize muscle spasms
 Reduce, align & immobilize fractures
 Reduce deformity
 Increase space between opposing surfaces
 Vectors of force are the lines of pull that counteracts
the other and are used to achieve the desired line of
pull.
 Whenever traction is applied counteraction must be
used to achieve effective traction.
 Counteraction is the force acting in the opposite
direction.
 Traction must be continuous to be effective in
reducing and immobilizing fractures.
 Skeletal traction is never interrupted.
 Weights are not removed unless intermittent traction
is prescribed.
 Any factor that might reduce the effective pull or alter
its resultant line of pull must be eliminated:
 The patient must be in good body alignment in the
center of the bed when traction is applied.
 Ropes must be unobstructed.
 Weights must hang freely and not rest on the bed or
floor.
 Knots in the rope or the footplate must not touch the
pulley or the foot of the bed.
 Types:
 Straight or running traction – applies the pulling force in
a straight line with the body part resting on the bed.(ex.
Buck’s extension traction)
 Balanced suspension traction – supports the affected
extremity off the bed and allows for some patient
movement without disruption of the line of pull.
 Skin traction - is applied to the skin.
 Skeletal traction – is applied directly to the bony
skeleton.
 Manual traction is applied by hands but is temporary
that may be used when applying a cast.
 It is used to control muscle spasms and to immobilize
an area before surgery.
 The amount of weight applied should not exceed the
tolerance of the skin.
 No more than 2-3.5 kg of traction can be used on an
extremity.
 Pelvic traction is usually 4.5-9 kg depending on the
weight of the patient.
 Types include:
 Buck’s extension traction applied to the lower leg)
 Cervical head halter (occasionally used to treat neck
pain)
 Pelvic belt (sometimes used to treat back pain)
 Skin breakdown
 Closely monitor the status of skin in contact with tape
or foam to ensure that shearing forces are avoided.
 Palpate the area of the traction tapes daily to detect
underlying tenderness.
 Provide back care at least every 2 hours to prevent
pressure ulcers.
 Use special mattress overlays (eg. Air-filled, high-
density foam) to prevent pressure ulcers.
 Nerve Damage
 When traction is applied to the lower extremities, care
must be taken not to put pressure to the peroneal nerve
which passes at the neck of the fibula just below the
knee. Pressure at this point will cause footdrop.
 Ask the patient about sensation and ask to move the
toes and foot.
 Immediately investigate any complaint of a burning
sensation under the traction bandage or boot.
 Promptly report altered sensation or impaired motor
function.
 Circulatory impairment
 After skin traction is applied, assess circulation of the
foot or hand within 15-30 minutes then every 1 – 2 hours.
Assessment will include:
 Peripheral pulses, color, capillary refill, and temperature
of the fingers or toes.
 Indicators of DVT, including unilateral calf tenderness,
warmth, redness, and swelling.
 Encourage patient to perform active foot exercises every
hour when awake.
 The traction is applied directly to the bone by use of
metal pin or wire (Steinmann pin, Kirschner wire) that
is inserted through the bone distal to the fracture,
avoiding nerves, blood vessels, muscles, tendons or
joints.
 Tongs applied to the head (Gardner-Wells or Vinke
tongs) are fixed to the skulls to apply traction that
immobilizes cervical fractures.
 This method of traction is used occasionally to treat
fractures of the femur, the tibia, and the cervical spine.
 Skeletal traction frequently uses 7 – 12 kg to achieve
the therapeutic effect.
 The weights applied initially must overcome the
shortening spasms of the affected muscles. As the
muscles relax, the traction weight is reduced to
prevent fracture dislocation and to promote healing.
 Skeletal traction is balanced traction, which supports
the affected extremity, allows for some movement, and
facilitates patient independence and nursing care
while maintaining effective traction.
 Maintaining effective traction
 Check the traction apparatus to see that the ropes are in
the wheel grooves of the pulleys, that the ropes are not
frayed, that the weights hand freely, and that the knots
in the rope are tied securely.
 Evaluate the patient’s position, because slipping down in
bed results in ineffective traction.
 Maintaining positioning
 Maintain alignment of the patient’s body in traction as
prescribed to promote an effective line of pull.
 Position the patient’s foot to avoid footdrop.
 Preventing skin breakdown
 The patient usually uses the elbow or the heel of the
unaffected foot in repositioning himself in bed,
therefore, the nurse should protect the elbows and heels
and inspect them for pressure ulcers.
 To encourage movement without using the elbows or
heels, a trapeze can be suspended overhead.
 Monitoring neurovascular status
 Assess the neurovascular status of the immobilized
extremity at least every hour initially and then every 4
hours.
 Instruct the patient to report any changes in sensation
or movement immediately so that they can be promptly
evaluated.
 Assist in active flexion-extension ankle exercises and
isometric contraction of the muscles 10 times an hour
while awake to decrease venous stasis to prevent risk for
DVT.
 In addition, elastic stockings, compression devices, and
anticoagulant therapy may be prescribed to help prevent
thrombus formation.
 Providing pin site care
 The goal is to avoid infection and development of
osteomyelitis.
 For the first 48 hours after insertion, the site is covered with a
sterile absorbent nonstick dressing and a rolled gauze. After
this time, a loose cover dressing or no dressing is
recommended.
 It is initially performed one or two times a day but the
frequency should be increased if mechanical looseness of
pins or early signs of infection are present (edema, purulent
drainage, erythema, tenderness). Chlorhexidine solution is
recommended as the most effective cleansing solutions;
however, water and saline are alternate choices.
 Hydrogen peroxide or betadine solutions have been used, but
they are believed to be cytotoxic to osteoblasts and may
actually damage healthy tissues.
  Crusting may occur at the pin site and should remain
undisturbed unless there are concomitant signs of
infection. Crusts provide a normal protective barrier,
and their removal may disturb healing tissue and make
it more vulnerable to infection.
 Promoting exercise
 Active exercises like pulling up on the trapeze, flexing
and extending the feet, and ROM and weight resistance
exercises for noninvolved joints should be regularly
done.
 Isometric exercises of the immobilized extremity are
important for maintaining strength in major ambulatory
muscles.