basics of slab and cast application

1. BASIC TRAUMA
MANAGEMENT IN
EMERGENCY SETTING
DR. NANDAN MARATHE
DR. S.K.SRIVASTAVA
DEPT. OF ORTHOPAEDICS
SETH GSMC AND KEM HOSPITAL

2. PRINCIPLES OF CASTING
• LUCAS CHAM- IMMOBILIZATION AND A LOT OF FUNCTIONAL THERAPY AND
MASSAGE LEAD TO FRACTURE HEALING.
• LORENZO BOHLER- IMMOBILIZING THE BONE FRAGMENT AND ADJACENT
JOINT IN A FUNCTIONAL POSITION.
SIR JOHN CHARNLEY

3. FRACTURE HEALING
TWO TYPES OF HEALING
DIRECT HEALING
• THE FRACTURE GAP IS VERY SMALL(LESS THAN 0.5) THIS HEALING OCCURS UNDER
CONDITION OF ABSOLUTE STABILITY(PLATE) WHERE REMODELLING OCCURS
WITHOUT CALLOUS FORMATION
INDIRECT HEALING
• THIS IS THE USUAL WAY OF HEALING IN NON- OPERATIVE FRACTURE CARE,
INVOLVES CALLOUS FORMATION

4. 3 R’S OF CASTING
• REDUCTION
• FRAGMENTS MUST REDUCED PROPERLY BEFORE CASTING AND PLACED IN A
FUNCTIONALLY ACCEPTABLE LIMB ALIGNMENT
• RETENTION
• FRAGMENTS MUST BE KEPT IN A REDUCED POSITION UNTIL HEALING OF BONE
OCCURS
• REHABILITATION
• FIRST THE FREE JOINTS HAS TO BE MOBILIZED DURING CAST IMMOBILIZATION
AND FOLLOWED BY MOBILIZATION OF ENTIRE LIMB POST CAST REMOVAL

5. 5,000 YEARS AGO EGYPTIANS BEGAN TO PRODUCE A POWDER BY
HEATING GYPSUM, WHEN MIXED WITH WATER IT FORMED A PASTE THAT
HARDENED AS IT DRIED, THEY USED THIS TO JOIN STONE BLOCKS FOR
BUILDING THE GREAT PYRAMID OF CHEOPS
PLASTER OF PARIS WAS ABUNDANT AND WIDELY USED BY PERSIANS FOR
BUILDING PURPOSE AND PARIS BECAME THE CAPITAL OF GYPSUM, HENCE
THE NAME PLASTER OF PARIS

6. FIRST USED BY A DUTCH MILITARY SURGEON ANTONIUS MATTHYSEN
IN 1952, HE DEVELOPED PLASTER BANDAGES DURING THE CRIMEAN WAR, BY
FILLING COTTON BANDAGES FILLED WITH POWERED POP.
THE MODERN POP BANDAGE CONSIST OF A ROLL OF MUSLIN STIFFENED BY
DEXTROSE/ STARCH WITH IMPREGNATED HEMIHYDRATE OF CALCIUM SULFATE

7. Antonius Matthysen- inventor of the plaster cast
Monument at his birthplace , Udel, in The Netherlands

8. CHEMICAL AND PHYSICAL FEATURES
• GYPSUM IS A SEDIMENTARY CRYSTALLINE ROCK, IT IS CALCIUM SULFATE
DIHYDRATE(CASO4. 2H2O)
• WHEN IT IS HEATED IT CONVERTS INTO CALCIUM SULFATE HEMIHYDRATE
(CASO4.1/2H20)
• CASO4.2H2O + HEAT - CASO4.1/2H2O + 11/2H2O
• THIS PROCESS IS CALLED CALCINATION
• WHEN WATER IS ADDED TO THIS HEMI HYDRATE
2(CASO4.1/2H2O)+3H2O ----> 2(CASO4.2H2O)+HEAT
THIS EXOTHERMIC REACTION IS RESPONSIBLE FOR THE FEELING OF
WARMTH FOLLOWING APPLICATION OF A POP SLAB/ CAST

9. SETTING TIME : 3- 9 MIN(START OF REACTION TO FORMATION OF CRYSTALLINE FORM)
DRYING TIME : 24 – 72 MIN ( CRYSTALLINE FORM TO AMORPHOUS FORM)
LOAD BEARING : 48 HRS
THE SETTING TIME CAN BE
INCREASED DECREASED
COLD WATER HOT WATER
SUGAR SALT
POTSSIUM SULFATE SODIUM BORATE

10. VARIOUS FORMS
• SLAB/ SPLINT: ONLY A PART OF CIRCUMFERENCE OF LIMB IS
INCORPORATED
• CAST: ENCIRCLE WHOLE CIRCUMFERENCE
• SPICA : CROSS BANDAGE APPLIED TO THE ROOT OF A LIMB
• BRACE: A DEVICE FITTED TO INJURED PART OF THE BODY, TO GIVE
SUPPORT

11. • SPLINT/ SLAB
• IF COMPLETE IMMOBILIZATION IS NOT REQUIRED( IN ORDER TO DECREASE SWELLING OR TO
PROTECT AGAINST SOFT TISSUE DAMAGE) NON CIRCUMFERENTIAL SPLINT MADE OUT OF POP
OR SYNTHETIC MATERIAL CAN BE USED
• USED IN POST OPERATIVE STABILIZATION, SHIFTING OF PATIENTS, SUPPORT TO REDUCE THE
SWELLING

12. • CAST
• IT IS CIRCUMFERENTIAL APPLICATION OF POP, DONE WHEN HIGH DEGREE OF
IMMOBILIZATION IS REQUIRED

13. • SPLIT CAST
• WHEN A CIRCUMFERENTIAL CAST IS APPLIED TO A FRESH FRACTURE OR POST
OPERATIVELY IT HAS TO BE SPLIT OPENED LONGITUDINALLY TO ALLOW SWELLING TO
OCCUR WITHOUT INCREASE IN PRESSURE, THE SPLIT CAST IS THEN WRAPPED WITH AN
ELASTIC BANDAGE

14. SPICA

15. BIOMECHANICS OF CAST
• IN # THERE MAY BE IMBALANCE BETWEEN THE FORCES ON THE
EXTREMITIES AND RESULTING IN DISPLACEMENT OF THE FRACTURE, THE
CAUSE OF THIS DISPLACEMENT COULD BE DUE TO DIRECT FORCE , OR
DUE TO THE LEVERAGE OF THE MUSCLE INSERTED
• A SUPPORT TO COUNTER THESE FORCES IS REQUIRED FOR STABILIZATION,
THIS DEPENDS ON THE AMOUNT OF FORCE ACTING ON THE # SITE( MORE
TENSION THE FOREARM # THAN CLAVICLE # HENCE THE FORMER
REQUIRES HIGH DEGREE OF IMMOBILIZATION)

16. • THREE POINT STABILIZATION OF THE # IS REQUIRED AS TWO POINT
STABILIZATION (PROXIMAL AND DISTAL) WILL NOT BE SUFFICIENT FOR
OF ANGULATIONS
• IN FOREARM # AE CAST/ SPLINT HAS TO BE GIVEN TO COUNTERACT THE
ACTING ON THE # SITE, BUT IN A ANKLE # WHICH IS FAR FROM THE
TIBIA ONLY AN BK CAST WILL SUFFICE TO COUNTERACT THE FORCE ACTING
THE # SITE

17. The three point principle, using the example of
a traction and reduction cast for the distal
radius using POP Point one dorsal moulded
rim
Point two palmar aspect, where the surgeons
palm is situated
Point three proximal shaft of the cast where
the four fingers are shown

18. IDEAL MATERIAL FOR CASTING
• DRIECT APPLICATION
• EASY TO MOULD
• NON – TOXIC
• UNAFFECTED BY FLUID
• TRANSPARENT TO XRAY
• EASY TO MODIFY
• EASY TO REMOVE
• CHEAP

19. • CONFORMABILITY AND PLASTICITY
• PLASTER SHOULD BE SUFFICIENTLY PLIABLE AND PLASTICALLY DEFORMABLE, TO CUT
THE CIRCUMFERENTIAL PLASTER ALONG A SINGLE LINE, THIS IS DONE IF THERE IS
SWELLING AND IMMEDIATE RELEASE OF POP IS REQUIRED, THIS PROCESS IS CALLED
UNIVALVING AS OPPOSED TO BIVALVING WHICH IS CUTTING ALONG TWO LINES
• POROSITY AND ABSORPTION
• IT MUST BE POURS TO ALLOW THE TRANSMISSION OF PERSPIRATION, WHICH ALLOW
SKIN MOISTURE TO DRY, POP ALSO ABSORBS WATER AND DISCHARGE FROM THE
WOUND AND LOOSES ITS RIGIDITY

20. • STRENGTH AND STABILITY
• DEPENDS ON THE CRYSTAL STRUCTURE AND IF THE CAST IS MANIPULATED WHILE IT
BECOMES HARDEN OR PREVENTED FROM DRYING OUT IT WILL BE WEAK BECAUSE OF
IMPAIRED CRYSTALLIZATION
• DEPENDS ON THE LAYER OF PLASTER AND THE SHAPE OF THE CAST CONTOURED
AROUND THE INJURED EXTREMITY
• THE WATER DEPTH SHOULD BE AT LEAST 20 – 30CM, THE IMMERSION TIME IS
APPROXIMATELY 3 SECONDS OR UNTIL AIR BUBBLES STOP APPEARING, THE PLASTER
MUST BE UNIFORMLY WET, DRY SPOTS FORMS PUFFY PASTRY PLASTER.
• IT IS IMPORTANT TO RUB THE MOIST PASTE INTO THE FABRIC IN ODER TO MAINTAIN A
SMOOTH, UNIFORM COMPOSITE
• LOW STRENGTH TO WEIGHT, 20% INCREASE IN THE WEIGHT OF POP WILL DOUBLE THE
STRENGTH

21. MATERIALS FOR CASTING
1)PLASTER OF PARIS:
MODERN POP ARE MADE BY GRINDING GYPSUM AND HEATING IT UNDER
PRESSURE IT IS MIXED WITH VARIOUS ADDITIES TO IMPROVE ITS HANDLING
CHARACTER, THE RESULTANT SLURRY IS ADDED TO LENO.
2)POP WITH MELAMINE RESIN: WATER RESISTANT CAST
3)MATERIALS WHICH UNDERGO POLYMERISATION
- WATER ACTIVATED
- NON WATER ACTIVATED
4) LOW TEMPERATURE THERMOPLASTICS

22. SYNTHETIC CAST MATERIAL
 SYNTHETIC CAST MATERIALS TYPICALLY CONSIST OF ONE LAYER OF
POLYESTER KNIT OR POLYPROPYLENE KNIT WITH FIBERGLASS FABRIC OR
FIBERGLASS FREE POLYMER (THE LATTER ALSO CALLED THERMOPLASTIC).
 THE IMPORTANT PART OF THE MATERIAL IS THE KNITTED FABRIC
IMPREGNATED WITH A POLYURETHANE RESIN, THE PREPOLYMER.
 THE RESIN POLYMERIZES AND HARDENS AFTER BEING EXPOSED TO
HUMIDITY OR WATER.
 GLOVES SHOULD BE USED DURING APPLICATION BECAUSE THE RESIN
ADHERES TO SKIN AND CAUSES IRRITATION

23. PROPERTIES
• MOLDABILITY IS LES THAN PLASTER
• RETAINS THE STRENGTH EVEN WHEN WET
• MODIFIYING THE RESIN POLYMER CAN FORM RIGID OR SEMIRIGID CAST

24. TYPES
• POLYSTER:
• POLYSTER FABRIC IS COATED WITH POLYURETHANE RESIN, STRENGTH
DEPENDS UPON THE NUMBER OF LAYERS, INTERFERES LESS WITH XRAY, THIS
PRODUCES LESS DUST DURING REMOVAL, IT CAN BE APPLIED AS A PRIMARY OR
SUBSEQUENT APPLICATION
• FIBERGLASS
• FIBERGLASS WITH POLYURETHANE RESIN PROVIDES RIGID DURABLE
IMMOBILIZATION, THE RIGIDITY DEPENDS UPON THE COMPOSITION OF RESIN
BASED ON THIS THEY CAN BE OF
• RIGID: IS APPLIED FOR PERFECT IMMOBILIZATION,
• SEMI RIGID: THEY ARE PLIABLE AND THEY ARE MEANT FOR MAINTAINING ALIGNMENT
DURING FUNCTIONAL USE,
• THE SETTING TIME IS 5 MINUTES AND WEIGHT BEARING AFTER 30 MINUTES

25. THERMOPLASTIC
• THIS CONSIST OF KNITTED POLYESTER WITH THERMOPLASTIC POLYESTER, THERE IS
NO RESIN HERE, THEY ARE REVERSIBLY MOLDABLE DEPENDING ON THE TEMPERATURE,
THE MATERIAL HARDEN ON COOLING AND CAN BE MOLDED ON HEATING

26. PLASTER OF PARIS VERSUS
SYNTHETIC CAST MATERIAL
• THESE INCLUDE:
• • GREATER MATERIAL COSTS OF SYNTHETIC
• • SHORTER WORKING TIME OR THE APPLICATION OF SYNTHETIC
• • LESS FREQUENT NEED OR RECASTING WITH SYNTHETIC
• • LESS ABRASIVE AND SMOOTHER EDGES IN SEMI RIGID SYNTHETIC
CASTING
• • HEAVIER WEIGHT OF POP
• • TIME REQUIRED OR COMPLETE SETTING WITH POP
• • THE AMOUNT OF HEAT THAT CAN BE PRODUCED IN POP, PARTICULARLY
WITH WARM DIPPING WATER OR A THICK PLASTER CAST.

27. RULES FOR CAST
• CAST SHOULD BE MOULDED WITH PALM
• ONE JOINT ABOVE AND BELOW
• CAST SHOULD NOT BE TOO TIGHT OR TOO LOOSE
• UNIFORM THICKNESS IS PREFERRED, APPLYING ROLLS
OVER EXTREMITIES PREVENTS EASY BREAKAGE

28. APPLICATION OF POP
• PADDING: PADDING IS DONE FROM DISTAL TO PROXIMAL WITH A 50% OVERLAP, MINIMUM 2
LAYERS, AND EXTRA PADDING AT BONY PROMINENCE(FIBULAR HEAD, PATELLA)
• LAYERS:
• 20 FOR ADULT LOWER LIMB
• 15 FOR ADULT UPPER LIMB
• 12 – 15 FOR CHILD UPPER LIMB
• 10 – 12 LAYER FOR CHILD UPPER LIMB
• SIZE:
8 INCH FOR THIGH
6 INCH FOR LEG
4 INCH FOR ARM AND FOREARM

29. APPLICATION OF SYNTHETIC CAST
• THERE ARE TWO DIFFERENT WAYS TO APPLY SYNTHETIC CAST MATERIAL.
• NORMALLY THE MATERIAL IS DIPPED INTO TEPID WATER (AROUND 18–20° C) AND
THEN APPLIED TO THE LIMB.
• THE WORKING TIME USING THIS TECHNIQUE IS ABOUT 2–4 MINUTES AND THE
INITIAL SETTING TIME TAKES ABOUT 6–8 MINUTES
• ANOTHER WAY O APPLYING SYNTHETIC CAST MATERIAL IS THE DRY APPLICATION
METHOD WHERE THE MATERIAL IS FIRST APPLIED TO THE LIMB AND THEN
MOISTENED BY SPRAYING WATER ON IT OR BY WRAPPING IT WITH A WET BANDAGE.
THIS TECHNIQUE GIVES MORE WORKING TIME

30. • UNPADDED PLASTER
• APPLYING WITHOUT ANY PADDING OR APPLIED OVER STOCKINETTE
• INTRODUCED BY BOHLER
• BANDAGE SHOULD ROLL ITSELF ROUND THE LIMB, NO TIGHTENINIG

31. • PADDED PLASTER
• COTTON WOOL IS APPLIED BETWEEN THE SKIN AND THE
PLASTER
• THE COTTON WOOL ENHANCES THE FIXATION DUE TO ITS
ELASTIC PROPERTY (TISSUE SHRINKAGE)
• ONE INCH THICKNESS OF COTTON ROLL IS APPLIED WHICH
GETS REDUCED TO 1/8TH ON APPLICATION PLASTER

32. TRIPLE SEQUENCE IN APPLICATION
• PHASE 1 : EXAMINATION AND REHEARSAL
• PHASE 2: PLASTERING
• PHASE 3: REDUCTION AND HOLDING

33. WEDGING OF CAST

34. MAKING A WINDOW

35. INSTRUCTIONS TO PATIENT ON PLASTER
• TO REPORT IMMEDIATELY
• INCREASED PAIN OR PINS AND NEEDLE
• FINGER OR TOES BECOME BLUE OR NUMB
• UNABLE TO MOVE YOUR FINGER
• YOUR UNABLE TO HOLD PENCIL OR COIN
• NOT TO REST THE CAST ON FIRM SURFACE
• NOT TO HANG THE LIMB
• TO DO MOVEMENTS OF THE IMMOBILISED JOINT
• TO KEEP THE PLASTER DRY

36. COMPLICATIONS
• DUE TO TIGHT CAST
• PAIN
• PRESSURE SORE
• COMPARTMENT SYNDROME: IF PT IS HAVING PAIN ON FLEXING/ EXTENDING THE FINGERS
THE PLASTER HAS TO BE CUT FULLY TO EVALUATE FOR COMPARTMENT SYNDROME
• PERIPHERAL NERVE INJURIES: WHEN ADEQUATE PADDING IS NOT GIVEN, COMMON
PERONEAL NEVER PALSY WHEN PADDING IS NOT GIVEN OVER FIBULA HEAD

37. • DUE TO IMPROPER APPLICATION
• JOINT STIFFNESS
• PLASTER BLISTER AND SORES
• BREAKAGE
• SLIPPAGE OF REDUCTION
• DUE TO ALLERGY
• ALLERGIC DERMATITIS

38. nandanmarathe88@gmail.com