Cast.pptx

Cast
• Objectives
– At the end of this lesson the students will be
able to
• Define the term cast
• Describe the indications and
contraindications for cast application.
• Identify the materials used in cast
application and cast removal.
• List and explain the steps to applying a
plaster cast and removing cast.
• List the complications of cast
• Discuss nursing cares for patient with cast
1
mulualem .B.(BSc,MSc)

A cast is a rigid external immobilizing device that is
molded to the contours of the body.
• A cast is used specifically:
 to immobilize a reduced fracture,
 to correct a deformity,
 to apply uniform pressure to underlying soft tissue, or
 to support and stabilize weakened joints.
2

Types of Cast
• Short arm cast
Extends from below the elbow to the palmar crease,
secured around the base of the thumb.
If the thumb is included, it is known as a thumb spica or
gauntlet cast.
The short arm cast may be used for:
Distal forearm fractures
Wrist sprains and carpal injuries
Some metacarpal fractures
3

Types of Cast
• Short arm cast…
4

…..Types of Cast
• Thumb spica cast
– The thumb spica cast may be used for:
• Scaphoid fractures
• Some thumb fractures
5

…….Types of Cast
• Long arm cast
Extends from the upper level of the auxiliary fold to the proximal
palmar crease.
The elbow usually is immobilized at a right angle.
The long arm cast may be used for:
Mid to proximal forearm fractures
Elbow fractures and dislocations
Distal humeral fractures
6

• Long arm cast…
7

• Short leg cast:
– Extends from below the knee to the base of the
toes.
8

……Types of Cast
• Long leg cast
–Extends from the junction of the upper and middle
third of the thigh to the base of the toes.
–The long leg cast may be used for:
• Tibial fractures
• Femoral fracture
9

……Types of Cast
• Long leg cast…
10

……Types of Cast
• Cylinder/stovepipe cast
–The cylinder/stovepipe cast may be used for:
• Patellar fractures or dislocations
• Distal femoral fractures (some)
11

……Types of Cast
• Cylinder/stovepipe cast
12

• Shoulder spica cast:
– A body jacket that encloses the trunk and the
shoulder and elbow.
13

………Types of Cast
• Hip spica cast:
– Encloses the trunk and a lower extremity.
14

Types of Cast
• Walking cast:
– A short or long leg cast reinforced for strength.
15

Types of Cast
• Walking cast:
16

Types of Cast
• Walking cast:
17

Cast Application
• Indications:
• Fractures
• Severe sprains
• Dislocations
• Protection of post-operative repairs
• Gradual correction of a deformity
18

Cast Application
• Contraindications:
Open fractures
Severe swelling
Ulcers or draining wounds
Compartment syndrome
Insensate limbs
19

Cast Application
• Equipments
– Stockinette
– Cotton
– Plaster of paris(POP)
– Bucket
20

Cast Application
• Equipments
–Stockinette
• Stockinette is usually the first layer applied
over the area to be cast.
• Its ends can be folded over the cast edges to
soften them.
21

Cast Application
• Equipments …Stockinette
22

Cast Application
• Equipments
–Cotton
• Cotton comes in a range of widths from 5-15
cm; the smallest ones are easiest to work with.
• 5-10 cm cotton should be used for the upper
extremity and 10-15 cm for the lower
extremity.
23

Cast Application
• Equipments …Cotton
24

Cast Application
• Equipments
–Plaster of Paris
• Plaster is the most commonly used casting
material.
• Immersion in water initiates an exothermic
reaction in the plaster causing it to harden.
• Once applied, it will feel hard within 4 minutes,
however, it takes 2-3 days to dry completely.
25

Cast Application
• Equipments…Plaster of Paris
26

Cast Application
• Equipments
–Bucket
• The bucket should be filled with water at or below
room temperature.
• Cooler water decreases the risk of burning the
patient’s skin as the plaster sets and
• also allows for more working time with the casting
material.
27

Cast Application
• Equipments-Bucket
28

Cast Application
• Equipments…Plaster of Paris
29

Cast Application
• Step 1: Evaluation
 the nurse should prepare the patient for the sensation of
increasing warmth so that the patient does not become
alarmed.
 Before cast application, certain examinations must be
performed:
Complete neurovascular exam of the affected region
Note the quality of the skin in the region to be cast
Radiographs as necessary
31

Cast Application
• Step 2: Prepare equipment
Choose appropriate width stockinette:
5 cm for arm
7.5 cm for leg
Prepare rolls of the appropriate width of plaster of
paris
7.5 cm for arm
10-15 cm for lower leg
20 cm for thigh
Fill plaster bucket with room temperature water.
32

Cast Application
• Step 3: Prepare patient
The patient should be positioned such that both they,
and the person applying the cast, will be comfortable
for the procedure.
For upper extremity casting, this
may sometimes involve propping the patients arm up
on a table or similar support.
For lower leg casts, the patient may sit with their leg
over the side of the bed or raised up from the bed on a
prop.
33

• Step 4: Stockinette
Measure the length of stockinette needed.
It should extend 3-4 cm beyond the area to be cast at
each end.
Using your own palm length as a guide, determine
where the thumb hole is to be cut.
34

Cont……d
• Step 4: Stockinette
At this location, cut a slit in the stockinette large
enough to give the base of the thumb lots of space.
Roll the stockinette over the area to be casted and
smooth it out.
Never apply plaster to skin or stockinette alone!
35

Cont……d
• Step 5: Cotton
Begin wrapping the cotton about 2 cm above where the
cast edges will be.
Beginning proximally, wrap the cotton distally,
overlapping the layers by 50%.
When you reach the hand, the cotton may need to be
torn to better contour the base of the thumb.
36

Cont……d
• Step 5: Cotton …
Once the hand is wrapped, continue back up the
forearm
Extra pieces of cotton folded to half their width
can be applied at either end of the cast for
smoother cast edges.
37

Cont……d
 Joints should be placed in their proper position of function
before, during, and after padding is applied to avoid areas of
excess wrinkling and subsequent pressure.
 In general, the wrist is placed in slight extension and ulnar
deviation, and the ankle is placed at 90 degrees of flexion.
Elbow at right angle.
mulualem .B.(BSc,MSc) 38

Cont…..d
• Step 6: Prepare plaster
Hold the plaster roll in one hand and the free end of the
plaster in the other
Holding the roll obliquely, immerse the entire roll of
plaster in water.
39

Cont…….d
• Step 6: Prepare plaster
 When the bubbles stop, remove the roll
and gently squeeze to remove some of the excess water.
 Do not squeeze too much water out or you will have less
working time and much of the plaster will be squeezed
back into the bucket.
40

Cast Application
• Step 7: Apply plaster
 As the plaster is being applied, it can be smoothed out with the
flat palmar surface of the hand. Not on your finger,
 The entire cast should use about 3 rolls of plaster.
 Start proximally and wrap towards the hand
 When applying plaster to the palm and between thumb and
index finger, pinch the plaster to decrease its width.
41

Cont…..d
• Step 7: Apply plaster…
Fold the plaster back on itself to create a thicker pad of
plaster to reinforce the palm, where much cast wear
occurs.
Fold the stockinette and cotton over the first layer of
plaster to create a smooth cast edge.
Continue to apply the final layer of plaster and smooth
outer surface.

• Step 8: Mould plaster
 The cast should be molded, depending on the type of
cast, to maximize its fit on the limb.
 Rub the cast to help the plaster layers adhere to each other
and give it a smooth surface
 To mould, apply pressure with the flat palmar surface of
your hands.
43

Cast Application
• Step 9: “Finish” cast:
Smooth edges.
Trim and reshape with cast knife or cutter.
Remove particles of casting materials from skin.
44

Cast Application
• Step 10: Support cast during hardening.
 Handle hardening casts with palms of hands.
 Support cast on firm smooth surface.
 Avoid pressure on cast.
45

Cast Application
• Step 11: Promote drying of cast.
Leave cast uncovered and exposed to air.
Turn patient every 2 hours supporting major joints.
Fans may be used to increase air flow and speed
drying.
46

Cast Application
• Step 12: Patient instructions
Keep the cast dry!
Plaster casts take 2-3 days to dry completely
To reduce and minimize swelling, the limb should be
elevated at a level of the heart for at least 2 days.
Fingers and toes should be wiggled often
47

Cast Application
• Step 12: Patient instructions…
– DO NOT:
• Put anything down the cast
• Trim or cut the cast
• Remove any padding from the cast
• Drive while in a cast.
48

How To Know if Something Is Wrong With Your Cast
 Pain that is not adequately controlled with medication
prescribed by your doctor.
 Increasing swelling
 Numbness or tingling in the extremity (hand or foot).
 Inability to move your fingers or toes beyond the cast.
 Circulation problems in your hand or foot.
 Loosening, splitting or breaking of the cast.
 Unusual odors, sensations, or wounds beneath the cast.
 If you develop a fever or generalized illness

Cast removal
 It is important to remember that removing a cast can be a
frightening experience for patients.
 A clear explanation of how the cast saw works will help
improve the patient’s comfort.
50

Cast removal
• Equipments
Cast saw
Cast spreaders
Bandage scissors
51

Cast removal
• Removing the cast (equipment)
–Cast saw
52

Cast removal
–Cast spreaders
53

Cast removal
–Bandage scissors
54

Cast removal
• Step 1: Cast saw
Inform and explain the patient about the procedure.
Cut two straight lines down either side of the cast moving
the saw in and out with brisk movements
56

Cast removal
• Step 1: Cast saw…
When making a cut, apply pressure until you feel the
release of the saw cutting through to the other side.
If the patient complains of pain, stop the saw and assess
the area.
57

Correct lines of cut for removal of plasters with the
hand and leg

• In hand plaster Only one cut is required, because the plaster is
thin enough to be opened out without difficulty when it has
been cut through. In the leg plaster two cuts should be made.
The first cut should be made along the lateral surface and
should pass behind the lateral malleolus, in the hollow
between the malleolus and the heel.
• Hence it should extend along the lateral border of the sole of
the foot. The second cut should be made along a
corresponding line at the medial side of the plaster, passing
behind the medial malleolus.

Cast removal
• Step 1: Cast saw…
60

Cast removal
• Step 2: Cast spreader
–Use the cast spreaders to widen the opening
made by the cast saw.
• Step 3: Cut through padding
–Use the blunt ended bandage scissors to cut the
cotton and stockinette.
61

Cast removal
• Step 4: Skin treatment
–Assess the skin that was under the cast for any
damage, and to ensure any incisions have healed.
–The skin can be washed with a mild soap.
–Apply emollient lotion.
62

Cast removal
• Step 4: Patient teaching
–Teach patient to avoid rubbing and scratching skin
–Teach patient to control swelling by elevating the
extremity or using elastic bandage if prescribed.
• The extremity is elevated (but no higher than heart
level, to minimize the effect of gravity on perfusion
of the tissues).
63

Cast
• Complications
– Compartment syndrome
– Pressure points/skin breakdown: This happens most
commonly with the peroneal and radial nerves.numbnes
– Skin irritation
– Loss of reduction(healing): As swelling subsides, the cast
will become looser, and fracture reduction may be lost.
– This can be avoided by following up with the patient 7-10
days after cast application, to ensure the cast still fits
properly.
– Disuse syndrome
64

Cast Care
• The following information provides general
guidelines
–Keep cast dry. Moisture weakens plaster and
damp padding next to the skin can cause
irritation.
–Walking casts. Do not walk on a "walking
cast" until it is completely dry and hard. It
takes about two to three days for plaster to
become hard enough to walk on.
–Avoid dirt. Keep dirt, sand, and powder away
from the inside of the cast.
65

Cast Care
• The following information provides general guidelines…
– Padding. Do not pull out the padding from the cast.
– Itching. Do not stick objects such as coat hangers inside
the cast to scratch itching skin. Do not apply powders or
deodorants to itching skin.
– Trimming. Do not break off rough edges of the cast or
trim the cast before asking your health professionals
66

Cast Care
• Swelling due to the injury may cause pressure in the
cast for the first 48 to 72 hours.
• This may cause the injured arm or leg to feel snug or
tight in the cast.
• It is very important to keep the swelling down.
• This will lessen pain and help the injury heal.
67

• Pain associated with the underlying condition (eg,
fracture) is frequently controlled by immobilization.
Pain due to edema that is associated with trauma,
surgery, or bleeding into the tissues can frequently
be controlled by elevation and, if prescribed,
intermittent application of cold packs.
Ice bags (one-third to one-half full) or cold application
devices are placed on each side of the cast, if
prescribed, making sure not to indent or wet the cast.

Cont……d
• Pain may be indicative of complications. Pain
associated with compartment syndrome is relentless
and is not controlled by modalities such as elevation,
application of cold if prescribed, and usual dosages
of analgesic agents.
• Severe burning pain over bony prominences,
especially the heels, anterior ankles, and elbows,
warns of an impending pressure ulcer

Cast Care
• To help reduce swelling:-
–Elevate.
• It is very important to elevate your injured
arm or leg for the first 24 to 72 hours.
• Elevation allows clear fluid and blood to
drain "downhill" to your heart.
–Exercise.
• Move uninjured, but swollen fingers or
toes gently and often.
• Moving them often will prevent stiffness
70

• Isometric contractions of the muscle maintain
muscle mass and strength and prevent atrophy.
• Quadriceps-Setting Exercise
• Position patient supine with leg extended.
• Instruct patient to push knee back onto the mattress
by contracting the anterior thigh muscles.
• Encourage patient to hold the position for 5 to 10
seconds. Let patient relax.Have patient repeat the
exercise 10 times each hour when awake.

• Gluteal-Setting Exercise
• Position patient supine with legs extended, if
possible. Instruct patient to contract the muscles of
the buttocks. Encourage patient to hold the
contraction for 5 to 10 seconds. Let the patient relax.
Have patient repeat the exercise 10 times each hour
when awake.
• For hand …instruct the patient ‘make fist’.

Cast Care
• To help reduce swelling…
–Ice.
• Apply ice to the cast.
–Place the ice in a dry plastic bag or ice
pack and loosely wrap it around the
cast at the level of the injury.
73

Cast Care
• Warning Signs
–Increased pain and the feeling that the cast is
to tight.
–Numbness and tingling in the hand or foot.
–Burning and stinging.
–Excessive swelling below the cast.
–Loss of active movement of toes or fingers.
74

Cast…..Nursing care
• Check color, temp, capillary refill, movement &
sensation of exposed part every 2 hrs for 24 hrs then
every 4 hrs.
• Change patient's position every 2 hrs.
while awake.
• Use proper positioning to keep pressure off
prominences in cast (i.e. heels).
75

Cast…Nursing care
• Check skin around cast edge every 4 hrs
• Monitor if there is any broken skin, foul odor or
drainage noted under cast edges.
• Provide daily nursing care.
• Teach family care of cast while in hospital.
76

Cast
• Key points
–Definition of cast
–Types of cast
–Cast application
• Equipment
• Procedure
–Cast removal
• Equipment
• Procedure
–Nursing care for pts with cast
77

Fixation
• Objectives
–At the end of this lesson the student will be
able to:-
Define what fracture fixation mean
Describe the difference between internal and
external fixation of fracture
Identify internal and external fixation materials
Discuss how to assist during fixation application
Discuss nursing care for patient with fracture
fixation
78

Fixation
• Fixation is the process of holding or fastening in a fixed
position
• Fracture Fixation is the immobilization of the parts of a
fractured bone especially by the use of various metal
attachments.
79

Fixation
• The basic goal of fracture fixation
To stabilize the fractured bone.
To enable fast healing of the injured bone.
To return early mobility and full function of the injured
extremity.
80

Types of fixation for fracture
1. External fixation
2. Internal Fixation
81

External fixation
 A device placed outside the skin that stabilizes bone fragments
with pins or wires connected to bars.
• Is a surgical treatment used to stabilize bone and soft
tissues at a distance from the operative or injury focus.
 Indication
Fractures with soft tissue damage
 Polytrauma – damage control surgery
 Skeletal infection.

• External fixation materials
–The most common external fixation
materials
Cast
Splint
Bandages
Traction
83

External Fixation
• Splint
– A splint is a device used for support or
immobilization of limbs or of the spins.
84

External Fixation
• Bandage
– A bandage is a strip of material such as gauze used to protect,
immobilize, compress, or support a wound or injured body part.
85

External Fixation
External Fixation Advantages
– Minimal damage to blood supply
– Minimal damage to soft tissues
– Fixation is away from site of injury
– Good option when significant infection risk
 External Fixation Disadvantages
– Restricted joint motion
– Pin tract infection
– Inadequate stability for certain fractures.
86

Fixation
• Risks and complications of fixation materials
Infection
Stiffness
Loss of range of motion
Non-union and mal-union
Damage to the muscles and nerve
Arthritis and tendonitis
Chronic pain associated with plates, screws, and pins
Compartment syndrome and Deformity
87

External Fixation
• Nursing Interventions
It is important to prepare the patient psychologically for
application of the external fixator.
After the external fixator is applied, the extremity is elevated to
reduce swelling.
If there are sharp points on the fixator or pins, they are covered
to prevent device-induced injuries.
88

• Nursing Interventions
The nurse monitors the neurovascular status of the extremity
every 2 to 4 hours and assesses each pin site for redness,
drainage, tenderness, pain, and loosening of the pin.
The nurse must be alert for potential problems caused by
pressure from the device on the skin, nerves, or blood vessels
and for the development of compartment syndrome
89

Internal Fixation for Fractures
Internal fixation is an operation in orthopedics that involves
the surgical implementation of implants for purpose of
repairing a bone.
Indications for Internal Fixation
 Displaced intra-articular fracture
 Axial, angular, or rotational instability that cannot be controlled by closed
methods
 Open fracture
 Polytrauma
90

• Benefits of Internal Fixation
Earlier functional recovery
More predictable fracture alignment
Potentially faster time to healing
91

• Internal Fixation materials for Fractures
– The most common types of internal fixation
materials are :-
• Wires
• Plates
• Pins
• Nails or Rods
• Screws

• Internal Fixation materials
–Wires
Wires are often used as sutures or threads to "sew" the
bones back together.
93

• Internal Fixation materials…
–Pins
Pins hold pieces of bone together.
They are usually used in pieces of bone that are too small to
be fixed with screws.
94

– Plates
• Plates are like internal splints that hold the fractured ends of
bone together.
• Extend along the bone and are screwed in place.
95

–Nails or Rods
• inserting a rod or nail through the hollow center of the bone
that normally contains some marrow.
• Held in place by screws until the fracture has healed.
96

– Screws
• Bone screws are used for internal fixation more often than
any other type of implant.
• Can be used alone to hold a fracture, as well as with plates,
rods, or nails.
• May be left in place, or removed after the bone heals.
97

Internal Fixation
– Screws
98

• Nursing Interventions…
– This typically includes cleaning each pin site separately three
times a day with cotton-tipped applicators soaked in sterile
saline solution.
– Crusts should not form at the pin site.
– Sterile conditions and advances in surgical techniques reduce,
but do not remove, the risk of infection when internal fixation is
used.
– The severity of the fracture, its location, and the medical status
of the patient must all be considered.
99

Key points
• Definition of fixation
• Types of fixation
– Internal
– External
• Fixation materials
• Nursing intervention for patient with fixation
100

Traction
• Traction is the application of a pulling force to a part of the
body.
• Purposes:
– To minimize muscle spasms
– To reduce, align, and immobilize fractures
– To reduce deformity
– To increase space b/n opposing surfaces
• As muscle and soft tissues relax, the amount of weight used
may be changed to obtain the desired effect.
101

Types of Traction
• The 3 basic types of traction are
– Manual
– Skin
– Skeletal
• The categories reflect the manner in which
traction is applied.

Principles of effective traction
 Whenever traction is applied, counter traction must be used to
achieve effective traction.
 Counter traction is the force acting in the opposite direction.
 Usually, the patient’s body weight and bed position
adjustments supply the needed counter traction.
104

Skin traction
 Used to control muscle spasms and to immobilize an area
before surgery.
 Uses a weight to pull on traction tape or on a foam boot
attached to the skin.
 The amount of weight applied must not exceed the tolerance of
the skin.
 No more than 2 to 3.5 kg of traction can be used on an
extremity
 Pelvic traction is usually 4.5 to 9 kg, depending on the weight
of the patient.
106

Cont.
108
Figure: Buck’s extension
traction
Lower extremity in
unilateral Buck’s extension
traction is aligned in a foam
boot and traction applied by
the free-hanging weight

Skeletal traction
 Skeletal traction is applied directly to the bone
 This method of traction is used occasionally to treat fractures of
the femur, the tibia, and the cervical spine
 The traction is applied directly to the bone by use of a metal pin
or wire inserted through the bone distal to the fracture
 Avoid nerves, blood vessels, muscles, tendons, and joints
during application.
109

110
Cont’d…
• Skeletal traction frequently uses 7 to 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.

• CONTRAINDICATIONS:
Patients with structural diseases secondary to tumor or
infection, rheumatoid arthritis and severe vascular
compromise.
Acute strains, sprains and inflammation condition
Malignancy
Aneurysm.

Traction Care
 The nurse must assess and monitor the patient’s psychological
responses to traction.
 It is important to evaluate the body part to be placed in traction
and its neurovascular status and compare it to the unaffected
extremity.
 As long as the client is in traction, skin integrity must be assessed
and documented, examining especially for redness, bruises, and
lacerations.
113

Traction care
 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:
114

Traction Care
 The patient must be in good alignment in the center of the bed when
traction is applied.
 Ropes must be unobstructed.
 Weights must hang free and not rest on the bed or floor .
 Knots in the rope must not touch the pulley or the foot of the bed.
115

Nursing Management:
 Alteration in Peripheral Tissue Perfusion:
 Tissue perfusion is enhanced by client exercises within the
limitations of the traction.
 Exercises, regular deep breathing and coughing, adequate
fluids, and elastic stocking work together to prevent deep
venous thrombosis.
116

Nursing Interventions:
 Peripheral sensation management :
 Evaluating the client’s pain, sensation, active and passive ROM,
color, temperature, capillary refill time, and pulses.
 Providing pin site care:
 The wound at the pin insertion site requires attention .
117

 Attaining maximum mobility with traction:
 During traction therapy:
 Encourage the patient to exercise muscles and joints that are
not in traction.
 During the patient exercises :
 Ensures that traction forces are maintained and that the
patient is properly positioned to prevent complications
resulting from poor alignment.
118

• Monitoring and managing potential
complications:
– Pressure Ulcers
– Venous Stasis and Deep Vein Thrombosis
119

quiz
1. writ the two types of fixation(2.5)?
2. Write the common nurses roles for post op
patients from cast replacement(2.5)?

Traction
• Reference
– Redemann S, Modalities for immobilization. In Maher A,
Salmond S, Pellino T, (Ed.), Orthopaedic Nursing,
Chapter 12, 311-318, 2002. Philadelphia: W B Saunders.
– Taylor I, Ward Manual of Traction, Chapter 2, 3, 5, 6.
1987, Churchill Livingstone.
– Traction Working Party, Traction update. Journal of
Orthopaedic Nursing, 6(4): 230-235, November 2002.
– 5National Association of Orthopaedic Nurses. (NAON).
Core Curriculum for Orthopaedic Nursing. 6th Edition.
Chapter 10. 2007.
121

Nursing Management:
 Alteration in Peripheral Tissue Perfusion:
 Tissue perfusion is enhanced by client exercises within the
limitations of the traction.
 Exercises, regular deep breathing and coughing, adequate
fluids, and elastic stocking work together to prevent deep
venous thrombosis.
122

 Peripheral sensation management :
 Evaluating the client’s pain, sensation, active and passive ROM,
color, temperature, capillary refill time, and pulses.
 Providing pin site care:
 The wound at the pin insertion site requires attention .
123

 Attaining maximum mobility with traction:
 During traction therapy:
 Encourage the patient to exercise muscles and joints that are
not in traction.
 During the patient exercises :
 Ensures that traction forces are maintained and that the
patient is properly positioned to prevent complications
resulting from poor alignment.
124

• Monitoring and managing potential
complications:
– Pressure Ulcers
– Venous Stasis and Deep Vein Thrombosis
125

Traction
• Reference
– Redemann S, Modalities for immobilization. In Maher A,
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