Cast Application Techniques for Common Pediatric Injuries

A Review

Karim Sabeh, MD; Amiethab Aiyer, MD; Spencer Summers, MD; William Hennrikus, MD

Disclosures

Curr Orthop Pract. 2020;31(3):277-287. 

In This Article

Upper Extremity Cast

Long Arm Cast

Materials Needed. Stockinette, three to four rolls of 2-inch or 3-inch cast padding, three to four rolls of 2-inch or 3-inch fiberglass or plaster. A clipboard can be utilized for molding.

Technique. The stockinette length should be 1 inch longer than the length of the cast on both sides to allow enough room to fold it in the end. Cut a small slit in the stockinette for the thumb. Ensure adequate cast padding application with two to three layers especially on bony prominences including the olecranon, ulnar styloid, and antecubital fossa. The cast padding needs to be snugly applied. Too much padding in the cast, more than four layers, can make the cast too loose. Ensure that the arm and wrist are in the desired position before application of cast padding because flexing or extending the elbow after application of cast padding can cause skin breakdown.

Start with two to three base wraps around the wrist then continue distally to include the distal palmar crease volarly and just proximal to the metacarpophalangeal (MCP) joint ensuring that the MCP joints are free and that opposition of the thumb to little finger is not obstructed. Use either the folding or cutting technique to navigate the fiberglass through the thenar space three times. Continue rolling proximally to include the elbow joint. A long arm cast should stop about 1 inch below the axilla. Avoid wrapping the cast material too tightly around the hand causing "cupping" in which the hand gets compressed in the radioulnar plane. The elbow should be at 90 degrees of flexion for most fractures, while the forearm and wrist are in a neutral position. The position of the cast can be adjusted, depending on the particular fracture pattern. Applying the edge of the casting tape over the antecubital fossa should be avoided. Supracondylar molding is helpful to prevent slippage of the cast (Figure 4). The injured arm is supported with a sling. The interosseous space should be molded flat to give a cast index of 0.7 (Figure 5). In addition, use a clipboard or wooden board to mold the posterior humerus flat.[14] For certain both-bone forearm fractures, placing a loop proximal to the fracture site can be helpful to maintain reduction while placing the arm in a sling (Figure 6).

Figure 4.

(A and B)With the child supine, the stockinette and cast padding are applied. (C) Fiberglass applied. (D) Flat humeral mold (Rang). (E) Flat ulnar border applied. Wrap final layer with the patient's color of choice.

Figure 5.

(A) Lateral view of right arm cast with flat back and straight ulnar boarder. (B) Birds eye view of right arm cast with flat posterior/anterior border. Cast index A/B ≤ 0.7.

Figure 6.

(A) Attachment of collar proximal to the fracture site with stuffed stockinette around the neck provides counterweight to align the fracture in the cast. (B) Attachment of the collar distal to the fracture site does not provide proper counterweight resulting in malalignment of the fracture in the cast. (C) Without the collar, the fracture will shift within the cast into malalignment.

Indications. A long arm cast is indicated for selected wrist, and elbow fractures as well as forearm fractures such as both-bone forearm (BBFA) fractures, humeral shaft fractures, proximal humeral fractures, supracondylar humeral fractures, medial and lateral epicondylar fractures, olecranon fractures, radial head or neck fractures, nursemaid's elbow, elbow dislocation after reduction, and Galleazzi and Monteggia radial and ulnar fractures.

Short Arm Cast

Materials Needed. Stockinette, two to three rolls of 2-inch or 3-inch of cast padding, two to three rolls of 2-inch or 3-inch fiberglass or plaster.

Technique. The stockinette length should be about 1 inch longer than the cast on both sides of the cast to allow enough room to fold it in the end. Cut a small slit in the stockinette for the thumb. Ensure adequate cast padding application with two to three layers especially on bony prominences, and particularly the ulnar styloid. Limit the padding to four layers to optimize molding of the cast. Place the forearm in neutral rotation, and the wrist in slight extension (10 degrees) while the thumb is in a position resembling holding a can of soda. Ensure that the wrist is in the desired position before application of cast padding. A tube stockinette can be placed over the thumb to ensure adequate padding of the digit when the cast is applied.

Start with two to three base wraps around the wrist then continue distally to include the distal palmar crease volarly and just proximal to the MCP joints ensuring that the MCP joints are free and that opposition of the thumb is not obstructed. Use either the folding or cutting technique to navigate the fiberglass through the thenar space three times. Continue wrapping proximally to two to three fingerbreadths distal to antecubital crease or one-third of the proximal forearm. The cast should be snug in order for it to be effective. The wrist should be in neutral generally; in select cases of distal radial fractures, slight wrist flexion or ulnar deviation is desirable to prevent loss of reduction. As mentioned above, the interosseous space should be molded flat to give a cast index of 0.7 (Figure 7).

Figure 7.

Application of a short arm cast.

Fiberglass has sharp edges and therefore a well-padded margin using stockinette flipped proximally and distally is helpful to avoid skin lesions.

Indications. A short arm cast is used as a transition from a long arm cast after a forearm fracture, for additional select distal radial, carpal, and metacarpal fractures, and for wrist fractures that include carpal bone fractures other than the scaphoid and base of second through fifth metacarpal fractures.

Thumb Spica Cast

Materials NeededStockinette (including thumb stockinette), two to three rolls of 2-inch or 3-inch of cast padding, two to three rolls of 2-inch or 3-inch of fiberglass or plaster.

Technique. Follow the same starting techniques as for short arm cast application, and add the thumb spica component. Place the forearm in a neutral rotation position, the wrist in slight extension (10 degrees), with the thumb in a position resembling holding a can of soda. Leave the interphalangeal joint of the thumb free for scaphoid or base of thumb injuries. Cast to the tip of the thumb for phalangeal injuries (Figure 8).

Figure 8.

Thumb spica cast.

Indications. The thumb spica cast is used for scaphoid fractures and select thumb ligamentous injuries and fractures.

Muenster Cast

Materials Needed. Stockinette, three to four rolls of 2-inch or 3-inch cast padding, three to four rolls of 2-inch or 3-inch fiberglass or plaster, and a cast saw. A clipboard can be utilized for molding.

Technique. This cast can be applied with or without a thumb spica component as determined by the injury. The cast is started by applying the stockinette and cast padding in an identical fashion to a long arm cast except it does not have to go quite as high on the brachium. Ensure that the forearm and wrist are in the desired position before application of cast padding. Roll the fiberglass or plaster spirally up the arm using a figure-of-eight technique around the elbow to the distal third of the brachium. Before the roll sets, make a transverse cut approximately 2 inches below the antecubital fossa anteriorly and extend it posteriorly to a level approximately 3 inches above the olecranon. The edges are trimmed appropriately, and the stockinette is brought down over the medial and lateral condyles. A mold is applied followed by the final roll of cast or plaster. The cast should allow 45 degrees of comfortable elbow motion with minimal pronation or supination.

Indications. A Muenster cast is indicated for scaphoid fractures, select both bone forearm injuries, and distal radioulnar instability injuries.

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