PRINCIPLES OF USE OF POP

Dr EJ D’Alton
POP – Plaster of Paris
• First applied in the treatment of fractures over 170 years ago

• Management of not only musculoskeletal injuries but other

ailments requiring immobilization

• Isn’t without risk, therefore sound knowledge and properly-

honed skills in its application
• Properties of POP first observed when a house in Paris built
on gypsum burnt down

• After rain fell, that the footprints in the mud were caked
upon drying

• First used in fracture care by Antonius Matthijses,

Dutch army surgeon in 1852
•POP is caso .½H O in its anhydrous form impregnated in gauze
4 2

• Obtained from heating gypsum to 120oc

• The hydration of caso4.½H2O converts it from powder form to

crystalline form

• This is the process of setting and is an exothermic reaction

Caso4.½H2O + 3/2H2O → caso4.2h2o
• POP incorporates 20% of the water its soaks UP

• Setting time – time taken to convert from powder form

to crystalline form

• Setting time is three times longer at 5oC than at 50oC

• Movement of the plaster while it is setting will cause gross

weakening
Drying time

• Time to loose excess water

• Influenced by ambient temperature and humidity

• It will be bone white when dry. If it’s slightly darker or even

has a hint of cream color to it then it’s still wet

• The optimum strength is achieved when it is completely dry

Types of POP
– Slab: POP encloses partial circumference
– Cast: POP encloses full circumference
– Spica: includes trunk and one or more limbs
– Brace: splintage which can allow motion at adj joints

– Unpadded
• No material interposed btwn POP & skin

– Padded
• Interposed material may be stockinette & wool or wool alone
Double shoulder spika
 Indications
• Fractures
• Ligament injuries
• Reduced dislocations
• Musculoskeletal infections
• Deformity correction
• Severe soft tissue injuries esp. across joints
• Post tendon repair
• Post-operatively to augment internal fixation
• Inflammatory conditions – arthritis, tenosynovitis
POP Wedging
• Advantages
– Slower setting
– Infinitely moldable when wet
– Cheap
• Disadvantages
– Heavy
– Messy
– Significantly weakened if cast is wet
– Only partially radio-opaque -- loose detail on x-ray
• Surgeon should examine the limb
• Documenting any skin lesions and neurovascular status
• Radiographs should also be reviewed
• The motions required to adequately reduce the fracture
should be rehearsed
• POP should be applied by the surgeon
• Procedure requires an assistant
 Technique
• As a guide to appropriate size
• Arm & forearm – 6”
• Wrist – 4”
• Thumb & fingers – 3”
• Thigh & leg – 8”
• Ankle & foot – 6”
• One joint above and below
• Joint should be immobilized in functional position
 Technique
• Padding should be adequate esp. over bony prominences

• POP shouldn’t bee too tight or too loose

• The plaster should be of uniform thickness throughout

• Check neurovascular status after cast application

• Control Xray for acceptability of reduction

Technique
• Materials
• POP bandage
• Crepe bandage (for slabs)
• Casting gloves
• Basin of water
• Bandage scissors
• Padding (Soffban®)
• Sheets
• Stockinette
• Adhesive tape
 Technique
• Fracture is reduced and assistant holds limb in position of function
• Stockinette is measured, extending 10cm beyond determined limits
of cast, and threaded over limb. Upper limbs: 2-3” wide; lower limbs:
4” wide
• Wool padding is applied gently but snugly, starting from distal to proximal with
50% overlap
• Padding is applied generally in 2 layers
• Padding sizes, hand: 2”, rest of upper limb: 3-4”; foot: 3”, rest of lower limb: 4-6”
 Technique
• POP application
• POP to be used is dipped completely with both hands into tepid or
slightly warm water and held there till bubbling stops
• Prior to this, for slabs, the required length is measured and layered. On
average 6-10 layers for upper limb and 12-16 layers for lower limb would
suffice
• It is then brought out and lightly squeezed to get rid of excess water
• If a slab is to be created, the wet plaster is kept on a flat surface and the
hand is run from one end to another to get rid of air bubbles which may
cause slab to be brittle and the layers to separate when dry
 Technique
• For slabs
– POP slab is applied and molded onto the limb contours
– Molding is only with palms
– Stockinette & padding are rolled over the edge of slab and crepe bandage is applied from
distal to proximal
– Slabs may be used alone or to reinforce casts
• For cast
– POP is applied in distal to proximal with 50% overlap
– POP is applied snugly, compressing padding thickness by 50%
– The padding is rolled over and the final turns of POP are rolled over it
 Technique
• Above Elbow
• An above elbow plaster cast or slab is applied from knuckles of hand (distal
palmar crease anteriorly] and covers lower two thirds of arm
• Below Elbow
• While distal extent is same as above, proximally the plaster ends below
elbow crease.
• Above Knee
• Distal extent is up to metatarsophalangeal joints and proximally it covers
lower two thirds of thigh.
• Below Knee
• Distal extent is same, proximal extent ends below knee.
 Technique
• Precautions:
• Where swelling is anticipated use a slab instead of cast, if a cast must be used then it should be well-
padded
• POP applied postoperatively may have to be split as swelling may be significant (e.g. post-tourniquet
release, inflammatory oedema)
Above knee POP
 Technique
• REMOVAL:

• Slabs are removed by cutting the bandage, carefully avoiding nicking the skin
• For casts
– Using shears
» Heel of the shears must lie between plaster and skin, avoiding bony prominences

» Avoid cutting over concavities

» The route of the shears should lie over compressible soft tissue

» The lower handle should be parallel to the plaster

– Using electric saw
» Do not use unless there’s wool padding

» Do not use over bony prominences

» The cutting mov’t should be up and down not lateral

» Do not use blade if bent, broken or blunt

 Aftercare
• Following POP application check neurovascular status and check
reduction by x-rays
• Counsel the patient on signs of neurovascular compromise –
excessive pain, excessive swelling, bluish or whitish discoloration
of digits
• Reinforce all cracks and weak areas with more POP locally
• Limb elevation reduces swelling, pain and risk of too tight cast
• Check if the POP is restricting mov’t
• Ensure that all joints not immobilized by cast have full range of
motion
 Aftercare

• Keep POP dry

• Any area of localized pain should be windowed as it may be
a developing pressure sore
• The patient should be reviewed in 1 – 2 weeks and x-rays
done to reaffirm maintenance of reduction
 Complications
• Due to tight cast
• Pain
• Pressure sores
• Compartment syndrome
• Peripheral nerve injury
• Due to improper application
• Plaster blisters
• Breakage
• Loose cast
• Due to allergy
• Allergic dermatitis
• Others
• Muscle wasting
• Skin abrasion/laceration
 Alternatives to POP
• POP with melamine resin

• Fiberglass
– Advantages
• Lighter
• Three times stronger than POP
• Impervious to water
• Radiolucent
– Disadvantages
• Costly
• Less pliable
• Requires gloves
Synthetic cast
Despite revolutionary advances in management of injury,
especially those of the musculoskeletal system, POP still
remains very useful in carefully selected cases, obviating the
need for unnecessary surgery with its attendant risks
• Apley’s system of orthopedics and fractures, 9th Ed, pp 698 –
700
• Pocketbook of orthopedics and fractures, 2nd Ed, pp 55 – 67
• http://boneandspine.com/plaster-of-paris/
• http://boneandspine.com/how-to-apply-plaster- of-Paris-cast/
• http://boneandspine.com/plaster-cast- application-and-
aftercare-of-the-plaster/
• http://www.slideshare.net/medicojack/plaster- opparis
• http://www.aafp.org/afp/2009/0101/p16.html