This document discusses various types of casts and splints used to immobilize and treat fractures in the upper and lower extremities. It describes long arm casts for forearm and elbow fractures, Colles casts for distal radius fractures, scaphoid casts for scaphoid fractures, below-knee casts for ankle fractures, and splints like aluminum-backed foam splints and mallet finger splints to immobilize finger fractures. Positions and applications of each cast or splint are outlined in detail.

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Rockwood-2020

2.  Long Arm Cast :
 The classic long arm cast with the elbow at
90 degrees and the wrist included in the cast
(Fig. 9-14) is less commonly used now
because forearm and elbow fractures are
often internally fixed, but it is still used for
less severe fractures, pediatric
forearm/elbow fractures, and some elbow
fractures in the elderly (e.g., olecranon
fractures)

3.  The cast is applied from just below the axilla
to just proximal to the metacarpophalangeal
joints of the digits but leaving the thumb
free. The wrist is placed in 30 degrees of
dorsiflexion and the elbow in 90 degrees of
flexion. In more minor fractures the wrist
may not be included and a full arm cylinder
is then applied.

5.  These casts are routinely used to treat
humeral diaphyseal fractures in the acute
phase. The arm is placed over the lower
chest with the elbow at 90 degrees. A collar
and cuff support can be used to maintain the
position. A cast is then applied as shown in
Figure 9-15, so that the top of the humeral
component of the cast is above the humeral
fracture

6.  An alternative to the hanging cast is the U-
slab or sugar-tong splint, in which a plaster is
placed from just below the axilla on the
medial side of the arm down and around the
elbow and then upward to just below the
shoulder . The slab is then bandaged into
position. In proximal humeral fractures the
slab can be extended above the shoulder, but
surgeons should be aware that this will
negate any beneficial reduction effects of
gravity. These casts are often replaced at 2
to 4 weeks by a functional brace.

8.  The Colles, or forearm cast, is the most
widely used upper limb cast and is used for
most distal radial and ulnar fractures as well
as for some carpal injuries. The cast extends
from below the elbow to just proximal to the
metacarpal necks of the digits with the
thumb left free (see Fig. 9-16). The
application of the Colles cast is frequently
preceded by the use of a dorsal plaster slab
(see Fig. 9-11), which is replaced by the cast
once the swelling has reduced.

10.  The scaphoid cast is commonly used to treat
scaphoid fractures and pain in the
anatomical snuff box on the radial border of
the wrist when radiographs do not confirm
the presence of a fracture. The wrist is held
in slight dorsiflexion and the thumb is in
abduction and slight flexion as if a glass is
being held between the index finger and
thumb

11.  The cast extends from just below the elbow
to just proximal to the metacarpal necks of
the digits. On the thumb the cast extends to
just proximal to the interphalangeal joint. A
modification of the scaphoid cast is the
extended scaphoid cast, which may be used
for fractures distal to the
metacarpophalangeal joint of the thumb. In
the extended scaphoid cast the whole thumb
is included.

13.  The Bruner cast is a variant of the extended
scaphoid cast that is cut short to release the
wrist joint. It is particularly useful for the
treatment of ligamentous injuries of the
thumb metacarpophalangeal joint but may
be used to treat associated minor avulsion
fractures

14.  This cast is used to treat metacarpal or
phalangeal fractures. The wrist is placed in 40
degrees of dorsiflexion and the
metacarpophalangeal joints are placed in 70 to
90 degrees of flexion (Fig. 9-18). The cast relies
on the intact dorsal hood of the fingers acting as
a tension band or a soft tissue hinge. It is usually
applied by placing a slab over the dorsum of the
forearm and the hand, with the wrist and fingers
in the correct position and then applying a
forearm cast to secure the slab. Finger extension
is not permitted by the dorsal slab but some
flexion is allowed.

16.  In this cast the fingers are kept in the
“position of function” of the hand. The wrist
is maintained at 40 degrees of dorsiflexion
with the metacarpophalangeal joints at 70 to
90 degrees of flexion and the interphalangeal
joints of the fingers in full extension
 In this position the collateral ligaments of
the metacarpophalangeal joints and the
interphalangeal joints are stretched
maximally and thus contractures will not
occur

17.  As with the Burkhalter cast, the James cast is
in fact a combination of a slab and a cast.
Initially a volar slab is applied to the forearm
and hand with the joints in the correct
position. A forearm cast is then applied.

19.  Below-Knee Cast
 This is the most common cast used for lower
limb injury, including ankle fractures, foot
fractures, and soft tissue injuries. It is
occasionally used to treat undisplaced lower
tibial diaphyseal fractures or minor pilon
fractures.

20.  The cast is applied from below the level of
the fibular neck proximally to the level of
the metatarsal heads distally with the ankle
at 90 degrees and the foot in the plantigrade
position (Fig. 9-20). The below-knee cast
may be applied as a first stage in a long-leg
cast used to treat an unstable tibial
diaphyseal fracture.

22.  Surgeons usually use a long-leg cast to treat
unstable tibial diaphyseal fracture in the
acute phase changing to a patellar tendon-
bearing cast after a few weeks. They may
also be used to treat fractures around the
knee. A long-leg cast is best constituted by
applying a below-knee cast and then flexing
the knee to about 10 degrees, following
which the thigh extension is applied

24.  The other variant of the below-knee cast is
the patellar tendon-bearing cast, which is
usually used to treat tibial diaphyseal
fractures after a few weeks in a long-leg
cast. In this cast the proximal end of a
below-knee cast is extended upward as far as
the lower pole in the patella and moulded
around the patellar tendon to provide a
degree of rotational stability (Fig. 9-22).
Care must be taken not to apply pressure
over the common peroneal nerve running
around the neck of the fibula.

26.  Several types of minor injuries, soft tissue
sprains, and minor fractures are treated by
support and analgesia with mobilization of
the affected area encouraged after a
relatively short period. Tubular elastic
support bandages are frequently used to
treat minor soft tissue injuries, such as ankle
and foot sprains, wrist sprains, or minor
ligament damage in other joints. Several
upper limb fractures are treated by the use
of slings, which may be supplemented by
bandaging.

27.  Fractures of the clavicle, proximal humerus,
and radial head and neck are often treated
by sling support until the discomfort settles
enough to allow joint movement. Many
different methods of bandaging have been
used to treat clavicle fractures in an effort
to reduce pain and maintain fracture
reduction. The figure-of-eight bandage
remains popular in the treatment of clavicle
fractures.

28.  Another area for which strapping is useful is in
the management of stable undisplaced fractures
of the phalanges of the hand and foot. These
fractures can be treated by buddy strapping the
affected digit to an adjacent digit (Fig. 9-32).
Usually two strips of half-inch tape are placed
around the proximal and middle phalanges with
protective gauze between the fingers. The joints
should be left free to permit mobilization. It
should be remembered that this type of
strapping loosens quickly and the patient, or
companion, should be taught how to replace it.

30. The use of an elastoplast thumb spica (Fig. 9-
33) may be helpful in treating sprains or
minor tears of the collateral ligaments of the
thumb. It can also be used for treating minor
associated avulsion fractures. unstable
fractures.

31.  These are constructed of elastoplast tape,
which is placed around the thumb and
extends down to the carpometacarpal area.
As with buddy strapping, they tend to loosen
quickly and need to be replaced. Neither
buddy strapping nor elastoplast spicas should
be used to treat

33.  Many different splints have been designed,
usually for the treatment of metacarpal and
phalangeal fractures. The two most popular
splints are the aluminium-backed foam splint
(Fig. 9-34) and the mallet finger splint (Fig.
9-35). Aluminium-backed foam splints are
used for phalangeal fractures.

36.  Aluminium-backed foam splints are used for
phalangeal fractures. They are commonly
applied to the volar or dorsal aspects of the
digits to immobilize fractures or joints after
reduction of a dislocation. They are also
useful for immobilizing the finger after soft
tissue injuries, and a volar splint may be
particularly helpful for maintaining extension
after a volar plate injury

37.  In more unstable fractures the surgeon may
elect to use an aluminium-backed splint in
the same way as a Burkhalter (see Fig. 9-18)
or James (see Fig. 9-19) cast might be used.
This is appropriate for a single digit fracture
and the splint is extended across the wrist
joint maintaining the position of the wrist as
described for the Burkhalter or James splint.

38.  Mallet fingers caused by either avulsion of
the extensor tendons from the distal phalanx
or by a fracture of the distal phalanx are
well treated by the use of a mallet finger
splint (seeFig. 9-35). An appropriately sized
splint is applied to the digit with the distal
interphalangeal joint in full extension