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principlesofuseofpop-210330190223.pdf
1. PRINCIPLES OF USE
OF POP
Dr. Sohail Razzaq
FCPS (ORTH)
Associate Professor of Orthopedic Surgery
Jinnah Hospital /Allama Iqbal Medical College Lahore.
2. Introduction
Definition
Statement of importance
Historical background
Physiochemical characteristics
of POP
Ideal cast
Classification
Indications
Advantages/disadvantages
Patient assessment
Rules guiding POP use
Technique
Materials
Application
Removal
Aftercare
Cast care instructions
Complications
Alternative casting materials
Conclusion
3. INTRODUCTION
POP – Plaster of Paris
First applied in the treatment of fractures over 150 years
ago
Proven indispensable in the non-operative management of
not only musculoskeletal injuries but other ailments
requiring immobilization as well.
Its use however isn’t without risk
Sound knowledge and properly-honed skills in its
application and care are necessary to maximize outcome.
4. Casting properties of POP were first observed when a house
built on gypsum burnt down in Paris. It was found after rain
fall, that the footprints in the mud were caked upon drying.
First used in fracture care by Antonius Mathijsen, A Dutch
army surgeon in 1852.
5. PHYSIOCHEMICAL
PROPERTIES OF POP
POP is CaSO4 .½H2O in its anhydrous form impregnated
in gauze which has been pre-strengthened with starch or
dextrose.
Obtained from heating gypsum to 120°C.
The hydration of CaSO4. ½H2O converts it from powder
form to crystalline form which gives rise to cast. This is the
process of setting and is an EXOTHERMIC REACTION,
CaSO4 .½H2O + 3/2H2O → CaSO4 .2H2O + Heat
6. POP incorporates 20% of the water it soaks up, the
remaining 80% is lost during drying.
Setting time – time taken to convert from powder form to
crystalline form
• Average time is 3 – 10 mins
• Reduced by high temp, salt solution, borax solution,
addition of resin
• Increased by low temp, sugar solution
7. Setting time is three times longer at 5°C than at 50°C
Movement of the plaster while it is setting will cause gross
weakening.
Drying time – time taken for POP to convert from
crystalline form to anhydrous form
• Influenced by ambient temperature and
humidity
• Arm cast: 24 – 36hrs
• Leg cast: 48 – 60hrs
• Hip spica: up to 7 days
The optimum strength is achieved when it is completely dry
8. AN IDEAL CAST
Suitable for direct application
Easy to mould
Non toxic
Unaffected by water
Transparent to x-rays
Quick setting
Able to transmit air
Strong but light weight
Non-inflammable
Non-messy
Long shelf life
Cheap
9. CLASSIFICATION
Based on pattern of application:
• Slab: POP encloses partial circumference
• Cast: POP encloses full circumference
• Spica: Bandage that is applied in successive V-shaped
crossings, includes trunk and one or more limbs
(Hip spica)
• Brace: Splintage which can allow motion at adjacent joints
10.
11. CLASSIFICATION
Based on interposition of material:
Unpadded
• No material interposed between POP & skin
• Practiced by Bohler
• Charnley recommended its use in Rx of Colles, scaphoid and Bennet fractures
• A practice in antiquity
Bologna cast
• Generous amount of cotton padding is applied to the limb before
putting cast
• Most commonly employed method
3-tier cast
• Interposed materials are stockinette & wool or cotton padding
• Best method but expensive
12. 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
13. Advantages
Slower setting
Infinitely moldable when wet
Cheap
Easy to remove
Durable
Heavy
Messy
Significantly weakened if cast is wet
Partially radio-opaque
Disadvantages
14. PATIENT ASSESSMENT
The surgeon should examine the limb and fracture
site, documenting any skin lesions and
neurovascular status
Radiographs should also be reviewed thoroughly
to determine fracture pattern
The motions required to adequately reduce the
fracture should be rehearsed ahead of
commencement of procedure
15. RULES GUIDING POP USE
POP should be applied by the surgeon
Procedure requires an assistant
A guide to appropriate size:
• Arm & forearm – 6”
• Wrist – 4”
• Thumb & fingers – 3”
• Thigh & leg – 8”
• Ankle & foot – 6”
16. RULES GUIDING POP USE
Apply POP one joint above and below
Joint should be immobilized in functional position
Padding should be adequate esp. over bony prominences
e.g. olecranon, ulnar styloid, patella, fibular head, malleoli,
heel.
POP shouldn’t be too tight or too loose
The plaster should be of uniform thickness throughout
Check neurovascular status after cast application
Do check x-ray for acceptability of reduction
18. TECHNIQUE
Prepare injured site
• Fracture is reduced and assistant holds limb in position
of function, in a manner that is unobtrusive to the application
of cast
• Stockinette is measured, extending 10cm beyond
determined limits of cast, and threaded over limb.
19. TECHNIQUE
Wool padding is applied gently and snugly, starting from
distal to proximal with 50% overlap between successive
turns, extending 2-3cm beyond edges of splint
Padding is applied generally in 2 layers, but may be
increased where there are bony prominences or if
significant swelling is anticipated
Padding sizes:
hand: 2”, rest of upper limb: 3-4”
foot: 3”, rest of lower limb: 4-6”
20. 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.
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 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.
6-10 layers for upper limb and 12-16 layers for lower limb would
suffice
21. For slabs
• POP slab is applied and moulded onto the limb contours
• Moulding 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
22. 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.
23.
24.
25.
26. POP 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 edema)
27. POP 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
29. 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 movement
Ensure that all joints not immobilized by cast have full range of motion
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
30. CAST CARE INSTRUCTIONS
Keep the cast clean & dry
Routinely check the cast for cracks or breaks
Do not scratch the skin under the cast by inserting objects
inside the cast
Do not put powder or lotion inside the cast
Encourage the patient to move his fingers or toes to
promote circulation
In case of itching, apply ice packs or place hair dryer (cool
air) against one end to draw air in through it
Any area of localized pain should be windowed as it may
be a developing pressure sore
31. WHEN TO COME BACK TO HOSPITAL
Cast is too tight
Develops fever
Increased pain
Increased swelling above or below the cast
Complaints of numbness or tingling
Drainage or foul odour from the cast
Cold fingers/toes
Cant move fingers/toes
32. COMPLICATIONS
Due to tight cast
• Pain • Pressure sores
• Edema distal to plaster • Circulatory compromise
• Compartment syndrome • Peripheral nerve injury
• Loss of functional limb (Gangrene, VIC)
• Disuse orteoporosis
Due to improper application
• Plaster blisters • Joint stiffness and malposition of limb
• Loose cast
Due to allergy
• Allergic dermatitis • Purulent dermatitis
Others
• Muscle wasting
• Skin abrasion/laceration
35. FIBER GLASS CAST
A plaster made from reinforced polymer of a plastic matrix
reinforced by fine fiber of glass.
Also called Glass-reinforced plastic (GRP) or Glass fiber
reinforced plastic (GFRP)
Fiberglass bandages are usually impregnated with
polyurethane
Mostly used in those cases where healing process has
already begun
36. FIBER GLASS CAST
Advantages Disadvantages
Lighter Costly
Faster setting Less pliable, more difficult to mould
3x stronger than POP Higher risk of pressure and constriction of limb
Impervious to water More prone to give rise to allergic reactions
Radiolucent Not used in acute conditions
37. CONTRAINDICATIONS
Open fractures
Impending compartment syndrome
Neurovascular compromise
Reflex sympathetic dystrophy
Skin infection or ulcers
Swelling of the limb
Allergy to cast material
Comminuted fractures
38. PLASTER DISEASE
When a limb is put into plaster and the joints are
immobilized for a long period of time, joint stiffness, muscle
wasting and osteoporosis are unavoidable.
This syndrome can be reduced to a minimum by the early
use of functional braces, isometric exercises and early
weight bearing, which in turn promote early retrieval of
function.
39. CONCLUSION
Despite revolutionary advances in management of
injury, especially those of the musculosketelal
system, POP still remains very useful in carefully
selected cases, obviating the need for
unnecessary surgery with its attendant risks
