What can go wrong?
There are many side effects of incorrectly applied plaster casts, so make sure you know the correct technique before applying a cast.
Minor consequences:
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Cuts and abrasions
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Discomfort
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Pressure sores (can be a major consequence depending on the severity)
Major consequences:
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Loss of fracture position
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Nerve damage
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Tissue and/or muscle death
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Compartment syndrome
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Infection from cuts or pressure sores
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DVTs – these can lead to pulmonary embolisms which can result in death
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​(London North West Healthcare, n.d; Sharma & Prabu, 2013)
The Basics
Applying plaster casts is an essential skill for those working in the emergency department.
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On this page you will find information on the consequences of incorrectly applied casts, the "Do's and Don'ts" of plastering, and some handy tips and tricks to make things easier.
The Do's and Don'ts
1. Always use cold water
Plaster sets faster if you use warm or hot water. Using cold water means you have more time to apply and mould the plaster
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2. Use your palms to mould, not your fingers!
Using your palms allows for even pressure to be distributed when moulding. Using your fingers can leave indentations in the cast, which can lead to pressure areas
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3. Always smooth the cast, including the edges!
A smooth cast is much stronger than a rough cast. Smoothing the edges avoids plaster splinters which can cut the patient
4. Always cut the plaster halfway when wrapping through the 1st web space
Cutting will avoid excessive bulkiness, which can make the thumb non-functional and cause extreme discomfort for the patient
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5. Always apply extra padding to bony prominences
Bony prominences are especially susceptible to pressure areas, particularly in elderly patient. A common presentation is a fractured distal radius in an elderly patient after a fall. Take particular care to pad the ulnar styloid in these patient as they are high risk for pressure areas!
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6. NEVER use tubigrip or compression when casting.
Always use a non-compressive stockinette to protect the skin. Using compression will result in the cast being too tight, which increases the risk of nerve damage, compartment syndrome, and development of DVT's.
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7. Always do a neurovascular check after applying the cast
Check that the patient has good capillary refill and movement before discharging them. This avoids any complications and associated medico-legal issues
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8. Know which fractures need admission, outpatient orthopaedic follow up, and which ones can be managed by the GP.
The Glasgow Fracture Clinic Redesign explores in detail which treatment is required by specific fractures. A summary of the management is available for download below. Note that fractures requiring 'referral to Virtual Clinic’ need to be referred to outpatient orthopaedic follow-up.
More information is also available from their website.
'Glasgow Fracture Clinic protocol' - Click on the paper clip to view
Tips and Tricks
1. Have everything laid out and run through a check list before you start.
The last thing you want is to be reaching for the scissors on another table when you’re halfway through a cast!
2. Use tape to create braces
This is demonstrated in the ‘Ankle Fracture’ tutorial video. Tape braces stop the patient from moving or breaking the cast before it is fully set. The tape braces can be removed after 24 hours.
3. Use pre-tape to hold slabs in place when plastering an ankle.
Pre-tape or adhesive underwrap is normally used when strapping athletes who are allergic to sports tape, however it is very handy for plastering. Use the pre-tape to anchor the slab in place while you prepare the second slab. The pre-tape acts as your second pair of hands, meaning that only one staff member is needed to apply the cast. This technique is demonstrated in the 'Back and U' tutorial video
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4. Give the patient handouts regarding plaster care.
Even though the plaster care has been explained to them, patients can forget. Providing handouts avoids patients representing unnecessarily. Handouts from the Royal Children’s Hospital (Melbourne, Australia) and the Victorian Department of Health are available below
Plaster care for Adults - Click on the paper clip to view
Plaster care for Children - Click on the paper clip to view
References
London North West Healthcare. (n.d). Complications of Plaster Cast. Retrieved from
www.lnwh.nhs.uk/EasySiteWeb/GatewayLink.aspx?alId=2615
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Sharma, H., & Prabu, D. (2013). Plaster of Paris: Past, present and future. Journal of Clinical Orthopaedics
and Trauma, 4(3), 107-109. doi:10.1016/j.jcot.2013.09.004