FRACTURE MANAGEMENT

Module 2. Fracture Management

* CASTS OF THE UPPER LIMB
* CASTS OF THE LOWER LIMB
* CASTS OF THE TRUNK / SPINE

CASTS OF THE UPPER

LIMB

Casts of the upper limb

* BELOW ELBOW / COLLES TYPE CAST1
* ABOVE ELBOW CAST1
* BENNETTS TYPE CAST1
* SCAPHOID TYPE CAST1
* HUMERAL BRACE1
* BELOW ELBOW PLASTER SLAB2
* ABOVE ELBOW PLASTER SLAB2
* U SLAB2

Below Elbow / Colles Type Cast

* ANATOMY & PHYSIOLOGY
* INDICATION
* DESCRIPTION
* CAUSE
* SIGNS & SYMPTOMS
* COMPLICATIONS
* TREATMENT PROTOCOLS
* GLOBAL ALTERNATIVES
* TERMINOLOGY

Below Elbow / Colles Type Cast

Anatomy &
Physiology
Familarity with specific
anatomical landmarks
is important.
Radius is always on
the thumb side of the
forearm and is the
shorter bone. Ulna
styloid tends to be
prominent and
requires additional
padding protection or
a shaped piece of felt /
foam.

Below Elbow / Colles Type Cast

Indication
Distal fracture of the radius, that may include the ulna.
Description
Classified in 1814 by Abraham Colles (1773-1843). Hence
tends to be known as a Colles cast.
Commonest of all fractures, within 2.5 cm of the wrist.
60-70% fractures affecting middle-aged to elderly
postmenopausal women.
10-15% fractures in younger patients, as a result of more
violent injuries.

Below Elbow / Colles Type Cast

Cause
Fall on the outstretched hand (FOTOH), with the wrist in
extension. The majority of individuals will put their hands
out as a natural preventive reflex when falling. The force of
impact, weight, age and position of the wrist are all
considered.

Below Elbow / Colles Type Cast

Sign & Symptoms
Classic dinner fork deformity. Posterior fragment
displacement.
Pain, swelling, ecchymosis and point tenderness on dorsal
aspect of the wrist
Movement restriction: disruption of the inferior radio-ulnar
joint, leading to supination impairment and palmar flexion
restriction.
Complications
Post-traumatic reflex sympathetic dystrophy (PTRSD) /
Sudecks atrophy
Delayed rupture of extensor pollicis longus tendon
Radial shortening
Residual grip weakness or stiffness

Below Elbow / Colles Type Cast

Treatment Protocol
Primary application:
Acute radio-dorsal plaster or synthetic splint, until
oedema has effectively reduced 24-48 hours post-injury.
Removable Colles type cast applications are also being
used as part of a functional approach.
Secondary cast application:
Case encasement:: 4-6 depending upon clinical
judgement

Below Elbow / Colles Type Cast

Global Alternatives
The traditional secondary treatment remains a fullycircumferential below elbow / short arm type cast. However,
alternatives are patient compliant dependent, with
functional splinting and or removable applications a growing
trend.
Equally, some areas prefer to apply an above elbow / long
arm cast, as a traditionary means to a shorter application,
in order to minimize pronation / supination of the forearm;
or a Munster type cast that incorporate s the elbow and
epicondyles, but allows flexion and some extension, with
the same rationale.
Optimum treatment has always been to ensure the cast is
both as comfortable as possible, but also as functional as
possible in order to minimize physiotherapy requirements,
post-cast removal.

Below Elbow / Colles Type Cast

Terminology
Carpus - wrist
Pisiform - pea-shaped
Triquetral - 3 articular faces
Lunate - crescent moon shape
Scaphoid - resembles a boat
Trapezium - 4-sided
Trapezoid - 4-sided
Capitate - largest carpal bone
Hamate - hook-shaped

Below Elbow / Colles Type Cast

Terminolo
gy
Extention:
Palm away
from you

Flexion:
Palm
towards you

Abduction:
Hand tilts
outwards
away from
the body

Adduction:
Hand tilts
inwards
towards the
body

Below Elbow / Colles Type Cast

Terminology
Anteriorly, cast extent
should ensure that the distal
palmar crease is visible,
permitting full function of
the fingers. Edge layering
and material pliability
provide functional comfort
for the patient. Material
comformability permits
excellent shaping in the
palm. Clinician can remove
gloves quickly after
application is complete for a
skin contact moulding.

Below Elbow / Colles Type Cast

Terminology
Cast extent distally /
posteriorly should come just
behind the knuckles or
metacarpal heads. Too
proximal will impair flexion
extension of the fingers and
too distal will not control the
potential for oedema.
Material durability will
ensure no breakdowns and
so minimize potential
returns and create
maximum cost benefit for
the hospital over the
treatment time.

Below Elbow / Colles Type Cast

Terminology
Thumb clearance around
thenar eminence, permitting
maximum grip / pinch
function. Thumb could have
a stockinette piece; this
would prevent patients from
picking at the padding and
provide more aesthetically
pleasing result. Cutting
around the thumb is ideal,
edges are smooth, requiring
minimal protection. Cast
surface is smooth to the
touch for maximum patient
comfort.

Below Elbow / Colles Type Cast

Terminology
Acute positioning is
generally slight ulnar
deviation, slight palmar
flexion, which tends to
follow the opposite parallel
to the injury impact.
Secondary approach tends
to be wrist in aneutral
position as shown in the
picture.
Layering provides a
focused strength choice,
allowing 4-5 layers over
the fracture site, 3-4 layers
through the main body of
the cast and 2 layers at

Below Elbow / Colles Type Cast

Terminology
Clearance in the antecubital
fossa should two-three
fingers width, permitting
sufficient clearance to allow
normal drinking activity and
minimal impact of the cast
against the biceps.

Below Elbow / Colles Type Cast

Terminology
Cast extent should flow
slightly diagonally from the
antecubital fossa towards
the elbow. Picture shows a
slightly straighter line of
material than is ideal.
Lamination quality will
provide fast, easy laydown.
Roll end should laydown on
previous turn and not
stockinette for optimum
result effectively.

Above Elbow Cast

* ANATOMY & PHYSIOLOGY
* INDICATION
* DESCRIPTION
* CAUSE
* SIGNS & SYMPTOMS
* COMPLICATIONS
* TREATMENT PROTOCOLS
* GLOBAL ALTERNATIVES
* TERMINOLOGY

Above Elbow Cast

Anatomy &
Physiology
Radius and ulna are
like two cones that
come together at the
ends, permitting
supination and
pronation as the
radius rolls around
the ulna.

Above Elbow Cast

Indication
Fracture of either the ulna or radius. Both bone shaft
fracture.
Description
Ulnar shaft fractures - approximately 70% midshaft/transverse.
Radial shaft fractures - most common at the middle to distal
third of the bone.
Fracture of the shafts of the forearm bones - common to
children.
Uncommon to fracture a single forearm bone.

Above Elbow Cast

Cause
Ulnar shaft - direct blunt trauma, defensive night stick
fracture.
Radial shaft - direct blunt trauma
Both bones - violent trauma/direct blunt trauma to the
forearm - motor vehicle accidents
Falls from height
Signs & Symptoms
Fracture site pain and oedema
Loss of hand / forearm function
Deformity - displacement dependent

Above Elbow Cast

Complications
Radial shaft - mal-union/non-union; distal radioulnar joint
subluxation
Both bones:
Cross-bone union
Compartment syndrome - both anterior & posterior
Mal-union/non-union - resulting from inadequate
reduction/immobilization
Cast extent pressure on the radial nerve as it winds around
the humerus - if undetected will lead to wrist drop
Shoulder stiffness/finger stiffness - patient falling to exercise
consistently during treatment period
Potential residual impairment of supination/pronation
Elbow stiffness - post cast removal

Above Elbow Cast

Treatment Protocol
Primary application:
Above elbow/long arm splint in plaster or synthetic.
Alternatively, a double sugar tong splint can be utilized
should increased stability be clinically preferred.
Secondary cast application:
Above elbow (AE)/long arm synthetic cast
Global Alternatives
Above elbow casts are also used for distal fracture of the
radius where limitation of pronation/supination is a clinical
preference. Scaphoid injuries are also seen to be placed in
an above elbow cast for a transitionary period prior to a
standard below elbow application.

Above Elbow Cast

Terminology
Pronation

Supination

Above Elbow Cast

Terminology
Final elbow position is 90. Initial
position is 85 flexion. This is
extended to the full 90, during
the application, prior to final set.
Such movement creates a slight
void underneath the cast,
minimizing any potential pressure
on the brachial artery.
Additionally, it is also advised that
a small length of padding is rolled
- similar to a sausage shape and placed in the crease after
stockinette, but prior to padding.
Equally, the flow of cast tape
application, directly across the
antecubital fossa should be for the
middle of the roll width to lay
across the crease, as opposed to
the roll edge. Such a combination

Above Elbow Cast

Terminology
Proximal cast extent
should be as high into the
axilla area as is
comfortable to the
patient. Axilla area tends
to be sensitive to heat, so
the patient should be
primed to anticipate this.
The flow of the cast
application should be
slightly superior in
relation to the axiilla
extent. Axilla cast extent
could be edged with a be
strip of adhesive felt for
additional patient
comfort; the nature of the
soft / pliable edge cast

Above Elbow Cast

Terminology
Olecranon and medial /
lateral epicondyles
should be protected
with shaped pieces of 2
mm adhesive felt or
equivalent pieces of
padding, particularly if
these areas are
prominent.
Cast extent distally /
posteriorly should come
just behind the
knuckles. Too proximal
will impair flexion
extension of the fingers
and too distal will not
control the potential for

Above Elbow Cast

Terminology
Wrist position is midpronation / supination,
with slight dorsiflexion.
Thumb and palmar area
are trimmed according
to patient comfort and
functionality. Distal
palmar crease is visible.
Web space and thumb
are trimmed-out for
maximum function,
permitting thumb to
touch as many fingers
as possible.

Above Elbow Cast

Terminology
Cast can be applied in one section or in two sections. This is
usually determined by fracture location. If the fracture is more
proximal on the forearm, then one whole application can be
undertaken. If the fracture is more distal, then a two-section
approach is advised. Essentially, a Colles-type application first,
followed by the extension proximally, above the elbow. With a
two-section application, care needs to be taken at the joint, with
an additional layer of padding applied, with the padding midpoint at the joint itself.

Bennetts-type Cast
* ANATOMY & PHYSIOLOGY
* INDICATION
* DESCRIPTION
* CAUSE
* SIGNS & SYMPTOMS
* COMPLICATIONS
* TREATMENT PROTOCOLS
* GLOBAL ALTERNATIVES
* TERMINOLOGY

Bennetts-type Cast
Anatomy &
Physiology

Bennetts-type Cast
Indication
Fracture dislocation of the first carpometacarpal joint at the
base of the thumb.
Description
Four defined types are categorized as to whether there is a
carpometacarpal joint impact: intraarticular, extraarticular
or epiphyseal.
Type I - Bennetts - usually oblique fracture line.
Intraarticular.
Type II - Rolandos - a T or Y fracture line involving the
joint surface. Intraarticular.
Type III - are extraarticular fractures, either transverse or
oblique.
Type IV - involve the proximal epiphysis of the thumb and
relate only to children.

Bennetts-type Cast
Cause
The majority of fractures of the
first metacarpal occur at or
near the base.
Fall, punch or blunt trauma on
the clenched first - with axial
load directed against a
partially flexed thumb.
Hyperflexion of the thumb
Forced abduction or
hyperabduction of the thumb
during a fall.

Bennetts-type Cast
Signs & Symptoms
Pain and swelling over radial aspect.
Deformity - with the distal shaft fragment of the thumb pulled
proximally, mainly by the abductor pollicis longus and the
proximal fragment is held in place.
Limited ROM of the MCP point.
Tenderness over the site, distal to the anatomical snuff box.
Complications
Instability - due to unopposed muscle action on the distal
fragment (by the abductor pollicis longus), attachment of the
proximal fragment to the trapezium and an oblique fracture line.
Mal-union - leading to chronic dislocation at the carpometacarpal
joint
Osteoarthritis - secondary to an inadequate reduction
Residual ROM impairment

Bennetts-type Cast
Treatment Protocol
Primary application:
Thumb spica - plaster or synthetic splint.
Secondary application:
4-6 weeks immobilization
Fragment instability may require a Kirschner wire/screw
fixation.

Bennetts-type Cast
Global Alternatives
There is no consensus as to whether the interphalangeal (IP)
joint should be enclosed, with the application to the thumb tip
or whether the IP joint should be left free; essentially
stabilizing the fracture within a scaphoid-type application. A
scaphoid-type application is sometimes more prevalent when
the fracture is transverse.
The principle of reduction is to apply traction to the thumb,
abducting it and applying pressure to the lateral aspect of the
base. General anaesthetic is used.
It is recognized that maintaining reduction is problematic.
Application-specific moulding is key to achieving an effective
outcome. Alternatively, screw fixation or two Kirschner wires
can be used to stabilize the thumb metacarpal.

Bennetts-type Cast
Terminolog
y
Flexion:
Thumb
moves across
palm of hand

Extension
:
Thumb
moves away
from hand

Abduction
:
Thumb
moves away
from hand
towards you

Adduction
:
Thumb
moves back
down to side
of hand

Bennetts-type Cast
Terminology
Cast extent is to just
proximal the tip of the
thumb, permitting
confirmation of blood
supply to the tip of the
thumb and
maintenance of
fracture stability.
Thumb is positioned in
mid-abduction.

Bennetts-type Cast
Terminology
Applicators thumb is
maintaining the
position of the thumb,
counterbalancing the
mould taking place
over the thumb base.
There is no forced,
direct pressure or
hyperextension of the
thumb, purely a
stabilizing force to
counterbalance mould
effect.

Bennetts-type Cast
Terminology
Ensure that a circle of
5 mm adhesive felt is
placed over the
padding so that it can
be felt through the
cast. Position the
adhesive felt so that
the mid-point of the
oval shape is over the
base of the thumb.

Bennetts-type Cast
Terminology
Cast extent distally /
posteriorly should
come just behind the
knuckles. Too
proximal will impair
flexion extension of
the fingers and too
distal will not control
the potential for
oedema effectively.
Anteriorly, to ensure
distal palmar crease is
visible.

Bennetts-type Cast

Terminology
Wrist is slightly
dorsiflexion.
Cast extent should flow
slightly diagonally from
the antecubital fossa
towards the elbow.
Picture shows a slightly
straighter line of material
than is ideal.

Bennetts-type Cast
Terminology
Clearance in the
antecubital fossa should
be two-three fingers,
permitting sufficient
clearance to allow
normal drinking activity
and minimal impact of
the cast against the
biceps.
Bennets extent
proximally can
commence slightly
shorter than a Collestype application
because the fracture is
more distal.

Bennetts-type Cast
Terminology
Slight pressure and
moulding is applied over
the mid-portion of the
felt and hence over the
fracture dislocation
itself. Such pressure
tends to force the
patients thumb towards
the palm and therefore
a counterbalancing
force is supplied by the
applicators thumb, in
order to prevent this
movement. A defined
concave indentation of
the cast should be
visible after initial set.

Scaphoid-type Cast
* ANATOMY & PHYSIOLOGY
* INDICATION
* DESCRIPTION
* CAUSE
* SIGNS & SYMPTOMS
* COMPLICATIONS
* TREATMENT PROTOCOLS
* GLOBAL ALTERNATIVES
* TERMINOLOGY

Scaphoid-type Cast
Anatomy & Physiology
There are 8 carpal
bones, with the
scaphoid being the
most significant from
an injury perspective.
Scaphoid = boatshaped

Scaphoid-type Cast
Indication
Fracture of the scaphoid.
Description
70% of carpal bone injuries involve only the scaphoid.
Fracture is usually transverse, often hairline, making
detection difficult - all suspected, but unconfirmed injuries,
tends to have repeat X-ray 10-14 days later.
Blood supply is distal, branching from the radial artery.
Commonest fracture sites:
Waist 50%
Proximal pole 38%
Distal pole 12%

Scaphoid-type Cast
Cause
Fall on the outstretched hand (FOTOH), with wrist in
extension.
Blunt trauma over the area

Scaphoid-type Cast
Signs & Symptoms
Pain on lateral aspect of the wrist.
Tenderness on dorsal aspect of the scaphoid.
Wrist flexion / extension impairment.
A small amount of swelling maybe visible, which may obscure the
concavity of the anatomical snuff box.
Weakness of pinch and pain on hyperextension of the wrist.
Complications
Avascular necrosis (AVN) - occurs in almost 30% of fractures
involving the proximal pole.
Post-traumatic reflex sympathetic dystrophy (PTSRD) or Sudecks
atrophy
Non-union
Osteoarthritis of the wrist

Scaphoid-type Cast
Treatment Protocols
Primary splint:
Plaster or synthetic scaphoid splint. Oedema tends to be
minimal, clinical decision can be to move to a
circumferential cast or a removable, functional cast.
Secondary splint:
Generally immobilization for 6-8 weeks, although this can
be dependent upon the location of the fracture: with a
waist fracture 8-10 weeks and proximal pole 10-12 weeks.

Scaphoid-type Cast
Global Alternatives
There is a trend towards immobilizing scaphoid injuries in a
Colles-type application, where the thumb piece is excluded.
Such an amendment provides full function to the thumb,
whilst maintaining appropriate stability.
Clinical evidence is beginning to support that a Colles-type
application shows equivalent healing rates to traditionally
applied scaphoid casts.
Equally, functional approaches with removable casts and
synthetic splinting regimes are additional alternatives that are
growing in popularity, as patient focus and patient quality of
life issues become more prominent.

Scaphoid-type Cast
Terminology
Scaphoid serves as the
principal bony block to
excessive extension of
the wrist. Scaphoid is an
important component in
the radiocarpal joint and
the joint between
proximal and distal row
of the carpus

Scaphoid-type Cast
Terminology
Fractures of the
scaphoid:
A = stable
B = unstable

Scaphoid-type Cast
Terminology
Cast extent distally,
permits visibility of the
distal palmar crease.
Such extent allows full
function the fingers and
flexion to 90 of the
metacarpophalangeal
joint (MCPs).
Excellent moulding
potential allows
applicator to follow
closely the natural
concavity of the palm
area and easy shape
around the thumb

Scaphoid-type Cast
Terminology
Thumb and index finger
opposition.
Remaining fingers should
not be able to touch
thumb tip or have
increasing degrees of
difficulty towards the little
finger.
The cast tape cuts and
conforms easily around
the thumb. Tension on
passage around the
thumb needs to be
maintained, allowing a
close fit. Tape, padding
and stockinette combine
to provide a confortable

Scaphoid-type Cast
Terminology
Cast extent distally /
posteriorly should come
just behind the
knuckles / MCPs. Too
proximal will impair
flexion extension of the
fingers and too distal
will not effectively
control oedema.

Scaphoid-type Cast
Terminology
100% X-ray
translucency is a
significant benefit with
this injury, permitting a
return confirmation Xray without the cost or
time hassle of cast
removal / reapplication;
allowing the limb
position to remain
undistrubed throughout
the treatment plan.

Scaphoid-type Cast
Terminology
Cast extent distally should
be to the interphalangeal
(IP) joint.
Usually cast is to the joint
on lateral side of thumb
and finishes, or is trimmed,
just under the IP joint
crease on the medial side.
This will allow some flexion
of the distal thumb without
compromising stability.
Post-trimming, thumb
should be able to touch
index and maybe middle
finger. Thumb touching of
fourth and fifth finger
should not be possible.

Scaphoid-type Cast
Terminology
The classical scaphoid
position is:
- slight dorsiflexion of
the wrist
- thumb and index finger
opposition]
- full pronation of the
wrist (although this
varies from a neutral
position to full
pronation)
- slight radial deviation
or the wrist

Scaphoid-type Cast
Terminology
Clearance in the
antecubital fossa to
three-four fingers.
Scaphoid extent
proximally can
commence slightly
shorter than a Collestype application
because the fracture is
more distal.
Cast extent should flow
slightly diagonally from
the antecubital fossa
towards the elbow.
Picture shows a slightly

Humeral Brace
* ANATOMY & PHYSIOLOGY
* INDICATION
* DESCRIPTION
* CAUSE
* SIGNS & SYMPTOMS
* COMPLICATIONS
* TREATMENT PROTOCOLS
* GLOBAL ALTERNATIVES
* TERMINOLOGY

Humeral Brace
Anatomy &
Physiology

Humeral Brace
Indication
Mid-shaft fractures of the humerus.
Description
2-4% of fractures involve the humerus, seen mostly in patients
over 50 years of age.
Four basic fracture patterns: transvers, oblique, spiral and
comminuted.
Mid-shaft fractures are associated with injuries to either the
shoulder or elbow.
Can be categorized based on displacement:
Class A: nondisplaced or minimally displaced
Class B: displaced and or angulated
Class C: markedly displaced with interposed soft tissues or
accompanied by neurovascular injuries

Humeral Brace
Cause
The type of fracture is dependent upon the mechanism of
injury , the force of injury, the location of the fracture and
the muscular tone at the time of injury.
Blunt trauma to the humerus from a direct blow or bending
force, usually results in a transverse fracture
Fall on the outstretched arm or elbow, usually diagnosed as
a spiral fracture
Violent muscle contraction - where bone is pathologically
compromised

Humeral Brace
Signs & Symptoms
Considerable diffuse swelling of mid-upper arm and
ecchymosis.
Severe pain focused around middle and proximal arm.
Shortening may be apparent with humeral displacement.
Abnormal mobility with crepitus.
Weak or absent dorsiflexion of the wrist or decreased
sensation on the back of the hand - suggesting radial nerve
impairment.

Humeral Brace
Complications
Radial nerve palsy: 5-10% or 10-15% (ulnar and median nerve
should also be assessed).
Soft tissue interposition, with elements of the biceps potentially
being trapped.
Non-union, mal-union or delayed-union
Treatment Protocols
Primary application:
U-slab or coaptation splint with collar and cuff.
Splints have a tendency to slide down, therefore, they need flow
over the acromioclavicular joint and to be practically attached to
the patients torso to prevent this migration.
Secondary application:
8-12 weeks cast/brace. FCT removable cast can be utilized from
the acute stage.

Humeral Brace
Global Alternatives
Initial treatment is directed at reducing fracture site
movement and correcting displacement, thereby reducing
pain levels. Swelling extent can be large and even minor
limb movement can be problematic .
These factors tend to increase the degree of difficulty from
a practical application perspective.
Humeral shaft fractures may be treated by several methods
depending on the type of fracture, the amount of
displacement and the presence of associated injuries.
Humeral fractures take 10-12 weeks for healing.

Humeral Brace
Terminology

Humeral Brace
Terminology
Patient are usually
asked to lean slightly
from the waist, in order
to create sufficient
axillary space to
comfortably permit
splint placement and or
cast roll passage.

Humeral Brace

Terminology
Apply standard
stockinette, cut a piece
of felt or foam for the
olecranon / epicondyles.
Roll and apply bouclette
to provide a terrytoweling effect on the
inside of the brace.

Humeral Brace
Terminology
However, prior to initial
set the patients
shoulders should be
brought back into
horizontal alignment
and be level. If the splint
or cast is allowed to set
before this is completed
the splint / cast will not
contour over the
acromioclavicular (AC)
joint or shoulder, lifting
upwards.

Humeral Brace
Terminology
Post application, mark
the cast surface for
landmarks and
trimming.

Humeral Brace
Terminology
Proximal superior extent
should flow well over
the AC joint. This will
ensure good
conformability and
sufficient material to
effectively trim.
The cast should be as
high and as close into
the axilla as is
practically and
comfortably possible.
Patient should be
primed to anticipate
heat in and around the

Humeral Brace
Terminology
Olecranon area should
be trimmed to permit
flexion / extension.
Distal extent should
include the medial and
lateral epicondyles in
order to control /
minimize rotation of the
forearm.
Cast application should
extent beyond the
antecubital fossa and
then trimmed back for

Below Elbow Plaster Slab

Application
The medical staff may prefer slabs to full casts. These are
made by measuring the length required, the extent being
the same as for a full cast. The required length is cut from a
plaster of Paris slab dispenser 15 or 20 cm wide, depending
on the size of the patients, or by forming a slab from 15 or
20 cm plaster of Paris bandage using 5 or 6 layers. The slab
are then shaped, trimming top and lower end as required.
The limb is positioned and padding applied as for a full cast.
The slab is folded concertina fashion and dipped into the
water holding the ends and maintaining the concertina folds.
It is removed from the water, squeezed gently and
straightened out. The slab is then carefully positioned on the
limb and smoothed to fit the contours.

Below Elbow Plaster Slab

Application
It is held in place with a wet cotton or crepe bandage. These
must be pre-soaked to avoid further shrinkage and to enable
them to adhere better. The end of the bandage is fixed with
a plaster of Paris strip.

Above Elbow Plaster Slab

Application
The ultimate position of the limb will be dependent on the
injury and displacement, if any, but will generally be about
90 at the elbow.
Prepare a 15 or 10 cm plaster of Paris slab, depending on the
size of the patient, using 5 layers. This slab should be long
enough to extend from the axilla to the knuckles of the
hand. Remember to allow a little for shrinkage of the
material.
Prepare also 2 x 10 cm slabs of 5 layers and 25 cm long.
Place these each side of the elbow joint to reinforce it. The
whole is then held in place by a pre-soaked crepe bandage.
Finish the application as for a below elbow slab.

Above Elbow Plaster Slab

U Slab
Padding
The humerus should be allowed to hang down in a straight
line to the body with the elbow at 90 and the palm facing
the chest. Do not let the patient lean over to one side or the
finished slab will be at the wrong angle and not sit down
onto the shoulder.
Measure and pre-roll a piece of 10 cm stockinette long
enough to reach from mid-forearm, up the arm and over to
the opposite shoulder.
Roll this onto the arm gently, cutting the roll just in front of
the axilla and opening it out onto shoulder up to the neck.
Cut the remainder in half and tie gently around the opposite
side of the neck.

U Slab
Padding
Apply a large semi-circle of 5 mm adhesive felt over the
shoulder and a piece around the elbow to protect the
olecranon process and the medial and lateral epicondyles.
Cover the arm with a layer of undercast.

U Slab
Application
Prepare a plaster of Paris slab 15 cm wide of 10 to 12 layers
which is long enough to travel the length of the cast plus a
few inches to allow for shrinkage. Apply the slab from the
axilla down around the elbow and back up over the shoulder,
fanning out the slab over the shoulder and moulding it to fit
snugly. Fix in position with a wet cotton or crepe bandage
and apply the collar and cuff to allow the arm to hang. This
brings the humeral fragments into alignment. Check that
there is no pressure on the neck or axilla. Trim the
stockinette and turn back over the edge of the slab, holding
in position with 2 layer strips of plaster of Paris.

U Slab

CASTS OF THE LOWER

LIMB

Casts of the lower limb

* BELOW KNEE CAST1
* ABOVE KNEE CAST1
* CYLINDER CAST1
* SARMIENTO TYPE CAST1
* BELOW KNEE SLAB2

Below Knee Cast

* ANATOMY & PHYSIOLOGY
* INDICATION
* DESCRIPTION
* CAUSE
* SIGNS & SYMPTOMS
* COMPLICATIONS
* TREATMENT PROTOCOLS
* GLOBAL ALTERNATIVES
* TERMINOLOGY

Below Knee Cast

Anatomy &
Physiology

Below Knee Cast

Indication
Distal tibial / fibula fractures, isolated fibula fractures, tarsal
fractures, metatarsal fractures, and or severe G3 ankle
sprains / strains.
Description
Lateral malleolar fractures result from inversion / adduction
forces.
Medial malleolar fractures result from eversion / abduction
forces.
Both injuries tend to involve ligament structures. Bimalleolar and tri-malleolar combinations tend to cause
major structural integrity problems of the ankle joint.

Below Knee Cast

Cause
Inversion / eversion trauma.
Falls from height.
Blunt direct trauma
Foot position, direction of
motion, intensity / direction
of forces and structural
resistance tend to determine
injury impact and
complexity.

Below Knee Cast

Signs & Symptoms
Pain and localized tenderness.
Localized oedema, ecchymosis.
ROM limitation / ankle instability.
Potential deformity if force causes displacement.
Complications
Predisposition to arthritis.
Recurrent sprains / persisting instability.
Post-traumatic reflex symphatetic distrophy (PTRSD) or
Sudecks atrophy.

Below Knee Cast

Treatment Protocols
Primary application:
Posterior splint in plaster or synthetic. A stirrup-type can
be used in isolation or in combination with the posterior
splint, depending on injury severity and clinical stability
required.
FCT/FRC removable cast applications can also be used
Secondary application:
Below knee non-weight bearing initially or weight bearing
cast for 6 weeks.
FCT removable cast applications can be continued
throughout treatment period.

Below Knee Cast

Global Alternatives
There is no consensus as regards an international
classification system, however:
Lauge-Hansen
Danis-Weber
Ashurst
Potts all tend to be the most common points of reference.
Trends with metatarsal injuries, particularly 2nd-5th
metatarsals is to treat with a removable cast, shaped to a
bespoke shoe; thus reducing ankle joint rehabilitation and
significantly benefiting patient functionally.

Below Knee Cast

Terminology

Inversion

Eversion

Below Knee Cast

Terminology
Cast trimming should ensure free toe movement,
particularly the fifth toe. Trim line should not extend beyond
comfortable flexion / extension, in order to constrain and
control potential oedema.

Below Knee Cast

Terminology
Choices for distal extent are just anterior to metatarsal
heads or as in this picture just beyond the toes - a toeplate,
shaped to follow the distal toe line and thereby creating
support and protection - that is more akin to a normal shoe.
Trimming so the cast finishes behind the metatarsal heads
should be avoided as this is will cause maximum discomfort
during a normal gait sequence.

Below Knee Cast

Terminology
Ensure cast application is well-moulded / laminated
throughout. Always continue to smooth and rub synthetic
materials during the working time period.
Ensure proximal cast application extends to tibial tuberosity /
tubercle. Stockinette and padding extend beyond this point.

Below Knee Cast

Terminology
Ensure clearance of over 90 of flexion, permitting maximum
patient comfort and functionality. Cast extent, posteriorly,
should flow slightly diagonally / inferiorly from the tibial
tuberosity around the gastrocnemius, in order to achieve this
result.

Below Knee Cast

Terminology
Ensure no pressure on the common peroneal nerve. Pad or
felt effectively around head and neck of fibula and avoid cast
tape tension in this area during application and or moulding.
Pressure at this point will increase the risk of foot drop
development and potential permanent limb disability.

Below Knee Cast

Terminology
Ensure integrated slab / splint for weight bearing. Slab can
extend from beyond toes to just over heel; or it can extend to
the proximal Achilles tendon / mid-calf, to provide additional
strength.
A 2-3 layer splint should be applied once a foundation layer
of cast tape is in place, i.e. cut from the second or third roll,
as required.

Below Knee Cast

Terminology
Ensure malleoli are adequately protected with either a piece of
shaped adhesive felt or an additional piece of padding,
particularly if the malleoli are prominent. A strip of padding
should be applied along the length of the tibia, if this is also
prominent. Ensure foot / ankle position is in plantigrade: i.e. no
inversion or eversion, with the ankle at 90. Such position
maintains the normal position of the foot when standing

Above Knee Cast

* ANATOMY & PHYSIOLOGY
* INDICATION
* DESCRIPTION
* CAUSE
* SIGNS & SYMPTOMS
* COMPLICATIONS
* TREATMENT PROTOCOLS
* GLOBAL ALTERNATIVES
* TERMINOLOGY

Above Knee Cast

Anatomy &
Physiology

Above Knee Cast

Indication
Shaft fractures of the tibia.
Description
Third tibia is subcutaneous - open fractures are common.
Tibial fractures tend to be associated with fibular fractures,
as opposed to being isolated.
Oblique and spiral fractures are common.
Tibia is relatively avascular and so depends on the
surrounding soft tissues for its blood supply. It is essential to
assess surrounding soft tissues.

Above Knee Cast

Cause
Direct violent trauma - motor vehicle accidents, falling rocks
or masonry. Direct trauma usually results in transverse or
comminuted fractures.
Indirect trauma - rotational / torsional forces in combination
with fall with a fixed foot, associated with skiing. Usually
results in a piral or oblique fracture.
Falls from a height can result in a tibial plafond fractures
that drives the talus up into the tibia.

Above Knee Cast

Signs & Symptoms
Patient inability to weight bear
Severe pain over fracture site
Localized oedema / ecchymosis
Potential deformity
Complications
Compartment syndrome - usually anterior
Ischaemia of distal fracgment
Skin necrosis over fracture site
Non-union, delayed union or mal-union
Persisting joint stiffness / pain
Soft tissue damage

Above Knee Cast

Treatment Protocols
Primary application:
Above knee backslab / long leg splint.
Secondary application:
Above knee / long leg cast including the foot for 5-12
weeks. Depending upon healing, cast can changed at 4-6
weeks for a Sarmiento / PTB-type cast in order to reduce
knee stiffness complications. This can be further reduced
after 2-3 weeks for a tibial brace or gaiter.

Above Knee Cast

Global Alternatives
The primary splint application tends to be the most
technically difficult aspect, with great care need to avoid
tibial movement. A number of experential methods have
been developed to manage around these innate difficulties.
Some clinicians prefer a two-part longitudinal medial /
lateral plaster slab, extending the full leg length. With the
leg resting on a series of plastic covered pillows, the lateral
and then medial slabs can be slid fluidly into place.
Alternatively, some clinicians prefer a two-part inferior /
superior splint, with the inferior splint positioned first to
minimize trauma, followed by the superior splint that
extends posteriorly above the knee and around the thigh.

Above Knee Cast

Terminology
Compartment syndrome:
A condition where there is increasing pressure within a
muscle compartment, which eventually leads to the death of
the muscle tissue.
Ischaemia:
An inadequate flow of blood to a part of the body, caused by
constriction or blockage of the blood vessels supplying it.
Necrosis:
Death of tissue, caused by physical injury or interference
with blood supply.

Above Knee Cast

Terminology
Care should be taken with layering to avoid a cast tape
edge coming across the patella. Where possible the roll
width should come directly over the patella, thereby
avoiding any potential ridge or ten.

Above Knee Cast

Terminology
Increasing overlap and tension over the soft tissue areas
will maintain a close fitting application.

Proximal extent is determined by comfort level in the

groin area, but should be as high as possible. Laterally,
the extent should be directed up towards the hip.

Above Knee Cast

Terminology
The join should have an additional single layer of
padding, to ensure patient comfort.

Distal extent: a foot plate or toe extension is the most

comfortable and effective extent; ensuring adequate
protection for the toes.

Above Knee Cast

Terminology
A 2-3 layer splint (toeplate) should be incorporated into
the cast to ensure sustained durability at weight
bearing. Splint length from the just beyond distal toes to
either heel stike point or up to mid-calf / proximal
Achilles.

Ankle / foot in
plantigrade.

Above Knee Cast

Terminology
Knee position should be maintained in 10-15 of flexion.

Above Knee Cast

Terminology
Cast should always be completed in two parts, allowing
either ankle or the knee position to be achieved first,
followed by the remaining joint. Provided the fracture is mid
to distal third, the first application part is the below the
knee section, with the ankle position achieved first. The
proximal edge of this cast should be graduated in order to
ensure that a smooth transition occurs as opposed to a step
change difference. Wait until this has set, then continue
with the above knee. One final roll should tie both halves
together and extend beyond the join area to the distal tibial

Above Knee Cast

Terminology
If the fracture is within the proximal third, then first
section should be as for a cylinder application, slightly
less distal extent. Second part should then include the
foot in the desired position. Additional splints are
sometimes utilized to reinforce medial / lateral and or
posterior aspects, depending upon clinical preference.

Cylinder Cast
* ANATOMY & PHYSIOLOGY
* INDICATION
* DESCRIPTION
* CAUSE
* SIGNS & SYMPTOMS
* COMPLICATIONS
* TREATMENT PROTOCOLS
* GLOBAL ALTERNATIVES
* TERMINOLOGY

Cylinder Cast
Anatomy &
Physiology

Cylinder Cast
Indication
Soft tissue injuries around the knee
Fractures of the patella
Description
Patella = small plate or kneecap.
Largest sesamoid bone. Increases leverage and efficiency of
quadriceps, triangular shape with apex pointing distally.
Fractures classified (non-displaced or displaced): transverse,
stellate or comminuted, vertical and osteochondral.
Transverse most common, followed by stellate.

Cylinder Cast
Cause
Direct trauma: falls or MVA - usually stellate / non-displaced.
Where the knee strikes the fascia, against a hard surface or
heavy objects falling against the knee.
Indirect: patients attempts to prevent stumble / fall, causing
forced quadriceps contraction which then initiates patella
fracture - usually transverse / displaced.
Against a hard surface or heavy objects falling against the
knee.

Cylinder Cast
Signs & Symptoms
Ability of patients to actively extend knee against gravity.
Absent ability signifies quadriceps mechanism disruption.
Tenderness / swelling over anterior knee.
Displaced fractures recognized by palpable separation /
defect.
Complications
Knee joint stiffness
Persistent instability and or weakness
Patello-femoral pain
Degenerative arthritis (relates to severe comminution)

Cylinder Cast
Treatment Protocols
Primary application:
Posterior splint, knee immobilizer with knee in full
extension. Ice and elevation usually form part of protocol.
Patients compliance needs to be confirmed. Patients
dislocations - knee immobilizer.
Secondary application:
4-6 weeks immobilization in a cylinder cast.

Cylinder Cast
Global Alternatives
There is no consensus as to treatment protocols. Some
clinicians prefer Orthopaedics Soft Goods (OSG)
immobilizer, some cylinder cast and some full leg casts
inclusive of the foot.
Splints are sometimes utilized to reinforce medial / lateral
and or posterior aspects, depending upon clinical
preference.
Combination POP / synthetic casts are frequently used, with
preference for the POP foundation layer because of the
shaped the mould over the femoral condyles that can be
achieved when using POP.

Cylinder Cast
Terminology

Dorsiflexion

Plantar flexion

Cylinder Cast
Terminology
2 mm felt protects the patient at the proximal edge.

5 mm felt. Distal edge should be placed above the

malleoli.

Cylinder Cast
Terminology
Where possible the middle of the cast tape roll should
flow over the patella, as opposed to the edge of a roll
coming across mid-patella. This will reduce any risk of a
tension ridge or inadvertent pressure of the patella
itself.
An additional layer of padding could be positioned
should the patella be viewed as prominent.

Cylinder Cast
Terminology
While working proximally, increasing overlap and
tension over the soft tissue areas will maintain a close
fitting application.

Extent of the cast proximally is determined by comfort

level in the groin area, but should be as high as possible.
Laterally, the extent should be to the hip.

Cylinder Cast
Terminology
Moulding: pressure is applied using the heel of both
hands, fingers flat, superior to the femoral condyles.
Pressure is applied evenly, internally and with a slight
anterior direction, in order to avoid forcing the knee
angle straight. Such pressure is sustained until the
material has retained the shape of the concave mould,
just above the condyles.
An effective mould will prevent the cylinder slipping
down toward the ankle.

Cylinder Cast

Terminology
Angle at the knee is between 5-10 of flexion. This is
attained and maintained throughout the material
application.
Patella fractures require knee to be in full extension.

Cylinder Cast
Terminology
Extent the cast distally is over the mid-point of the felt and
thereby above the malleoli. Felt maintains comfort should be
any slippage of the cast during ambulation over the
treatment period.
Cast application would be normally commence at this point,
moving proximally.

Sarmiento-type Cast
* ANATOMY & PHYSIOLOGY
* INDICATION
* DESCRIPTION
* CAUSE
* SIGNS & SYMPTOMS
* COMPLICATIONS
* TREATMENT PROTOCOLS
* GLOBAL ALTERNATIVES
* TERMINOLOGY

Sarmiento-type Cast
Anatomy &
Physiology

Sarmiento-type Cast
Indication
Fractures of the shaft of the tibia 4-6 weeks post injury, or
when the fracture is beginning to unite
Description
Third of tibia is subcutaneous - open fractures are common.
Tibial fractures tend to be associated with fibular fractures,
as opposed to being isolated.
Oblique and spiral fractures are common.
The tibia is rarely fractured alone. Studies indicate around
22% of tibial fractures relate solely to the tibia. 78% also
sustain a fracture of the fibula.

Sarmiento-type Cast
Cause
Direct violent trauma - motor vehicle accidents, falling rocks
or masonry. Direct trauma usually results in transverse or
comminuted fractures.
Indirect trauma - rotational / torsional forces in combination
with fall with a fixed foot, associated with skiing. Usually
results in a spiral or oblique fracture.
Falls from a height can be result in a tibial plafond fracture
that drives the talus up into the tibia.

Sarmiento-type Cast
Signs & Symptoms
Inability to bear weight.
Aching pain
Complications
Compartment syndrome.
Ischaemia of distal fragment
Skin necrosis over fracture site
Non-union, delayed union or mal-union
Persisting joint stiffness / pain
Soft tissue damage

Sarmiento-type Cast
Treatment Protocols
Secondary application:
Above knee cast for 4-6 weeks.
Tertiary application:
4 weeks in a PTB / Sarmiento-type cast. Option is to
change the cast after this period in order to free up the
ankle joint. Cast would be changed for a tibial brace or
gaiter. The brace would further free up the knee and
permit normal range of motion around the ankle joint.

Sarmiento-type Cast
Global Alternatives
The traditional Sarmiento-type application shown below
predominates; with either a combination POP / synthetic
preference. However, perspectives as to the effectiveness
of patellar ligament moulding, condylar wings and midpatella enclosure, have led to a trend towards a Miami-style
application.
The Miami-style takes the view that soft tissue
compression is the fundamentally important element of the
application. Therefore, the cast extent distally remains the
same. Proximally, the cast extent is to the tibial tuberosity
anteriorly and sufficiently high posteriorly to permit only 90
degrees of flexion - maintaining soft tissue support, control
and stability.

Sarmiento-type Cast
Terminology

Flexion

Extension

External rotation

Internal rotation

Sarmiento-type Cast
Terminology
Padding: 1 layer running
down the tibia, 2 layers
around the patella and 2
layers (50%) overlap
around the ankle and foot.
Felt bony prominences as
required.
2 layers of stockinette,
extending beyond the
patella and toes.
Position: ankle / foot
should be in plantigrade,
quadriceps relaxed. This
position should be
achieved prior to and then
maintained throughout
the application.

Sarmiento-type Cast
Terminology
Either a 1 or 2 layer
slab should be
incorporated over the
patella, extending to
the femoral condyles.
The trim line should
extend from midpatella to the femoral
condyles, forming
wings that are
designed to reduce
rotation. This effect is
more superficial than
practical in its effect.

Sarmiento-type Cast
Terminology
Final cast extent,
post trimming, in the
popliteal area, should
permit only 90 of
flexion. Having more
than 90, as with a
below knee walking
cast, would not
maintain effective
soft tissue
compression.

Sarmiento-type Cast
Terminology
Final cast extent
proximally is to midpatella. Initial
application would
encompass the
patella, but trimming
would achieve the
position shown. Any
higher than midpatella would impair
knee extension and
limit a natural gait.

Sarmiento-type Cast
Terminology
Moulding to shape the
patellar ligament. End
result is more a Vshape than finger
point indentations.
Care should be taken
to follow the ligament
as shape and not
encroach into the knee
joint border.
Cast should always be
externally marked:
minimal padding.
This will ensure care
on removal

Sarmiento-type Cast
Terminology
Soft tissue
compression is a key
element of this
application.
Smoothing, with
pressure, distal to
proximal, in order to
create a very close
fitting and effective
cast.
Flattening the
gastrocnemius with a
wooden block tends
to artificially alter the
natural shape and
function of the
muscle and is

Below Knee Slab

Application
Position of the ankle depends on the injury being treated, but is
most commonly held at 90 and the foot in neutral inversion /
eversion. If the knee can be held at an angle of 10-15 with the aid
of a padded support e.g. knee rest, it is easier to hold and
maintain the foot in the correct position. It is very important not to
let the ankle be moved during the application, as it is all too easy
to make ridges around the ankle.
The slab should extend from just below the knee, but allowing free
movement of that joint, to the toes.

Below Knee Slab

Application
According to the medical officers wishes the toes can be fully
exposed or supported by a platform.
There are certain injuries, which require different positioning. For
example, an injury to the Achilles tendon may require the foot to be
positioned in equinus and this may be achieved more easily by
placing the patient prone on the trolley. A difficult reduction of a
fracture may require the patient to be positioned with the knee at a
right angle over the edge of a trolley, the foot being supported on the
medical officers knee, thereby leaving both hands free to hold the
reduction.

CASTS OF THE TRUNK /

SPINE

Casts of the trunk / spine

* PLASTER JACKET2
* PLASTER CORSET2
* MINERVA JACKET2
* SHOULDER SPICA2
* HIP SPICA2
* FROG TYPE CAST2

Plaster Jacket
As stated previously, the actual position of the patient will be
decided by the medical officer but for clarity of application
we will presume that the jacket is applied with the patient
standing upright.
The cast extends from the top of the sternum to the
symphysis pubis anteriorly, and from the lower edge of the
scapula to the coccyx posteriorly. It should be trimmed at
the lower edge to allow the patient to sit comfortably and
also under the axilla to allow full movement of the arms. An
abdominal window can be cut and the gamgee removed.

Plaster Jacket
Padding
Stockinette is applied and
taped over the shoulders.
The circle of gamgee is
placed over the diaphragm,
and felt squares placed
over each iliac crest and
one down the spine over
the sacral area. Nonadhesive tape felt is
preferable as it can be
adjusted more easily and
gives no risk of an allergy.
These are all held in place
by single layer of undercast
padding.

Plaster Jacket
Application
Following basic rules casting is
then commenced from top or
bottom and 2 or 3 15 cm
plaster of Paris bandages
applied. Two plaster of Paris
slabs, 20 cm wide by 35 cm
long, are then positioned
down each side and one slab,
20 cm wide by 40 cm long,
down the central back. A
further 2 or 3 bandages are
then applied. A further slab,
20 cm wide by 30 cm long,
may be required across the
top front of the chest,
particularly in tall patients.
Before the cast has set it is
moulded well over the top of
the iliac crests as this area will

Plaster Jacket

Plaster Corset
If a corset is asked for it
is applied in the same
way, but extends from
just below the bust to
symphysis pubis. All casts
are finished off by turning
back the stockinette and
holding it in place with
strips of plaster or
adhesive stretchy tape.

Plaster Corset
Padding
Stockinette is applied and taped over the shoulders. The circle
of gamgee is placed over the diaphragm, and felt squares
placed over each iliac crest and one down the spine over the
sacral area. Non-adhesive tape felt is preferable as it can be
adjusted more easily and gives no risk of an allergy. These are
all held in place by single layer of undercast padding.
Application
Use 10 or 12.5 cm casting material depending on the size of
the patient. Apply from top or bottom edge covering at least
50% of the previous turn. Use a slab 10 cm x 30 cm long slab
of 3 layers across the posterior lower edge sandwiched
between the layers. Using strategically placed slabs allows you
to cut down on the total material used and strengthen selected
areas. Mould and trim as described for plaster of Paris. The
edges may need padding with 2 mm adhesive felt.

Minerva Jacket
* PLASTER OF PARIS
* Padding
* Application
* SYNTHETIC
* Padding
* Application

Minerva Jacket
First you need to organize a team to apply this cast. The
position of the patient will, of course, be dependent on the
type of injury and the medical officers instructions. A better
fitting cast can be applied with the patient standing or sitting
with or without some form of cervical traction. Therefore an
overhead hook may be required. If the patient has to by
supine, then a frame, table or hip spica table can be
adjusted to accommodate them.
Whichever position is chosen the medical officer ought to
take personal responsibility for placement and maintaining
the desired position.
If the patient wears glasses or dentures, make sure that
these are in situ before commencing application. The jacket
extends from the symphysis pubis to the chin anteriorly and
from the coccyx to the upper border of the occiput
posteriorly, with a band of plaster carried from the occipital
portion across the forehead anteriorly, and the ears left free.

Minerva Jacket
PLASTER OF PARIS
Padding
Apply stockinette, fixing the body part to the head part with
non-allergic tape and also fix across the shoulders. Pad the
iliac crests and sacral area with non-adhesive felt squares.
Place the circle of gamgee over the diaphragm and 2 small
circles over the ears under the stockinette. The gamgee can
then be removed through abdominal and ear windows
during trimming. Apply a layer of undercast padding overall.

Minerva Jacket
PLASTER OF PARIS
Application
Apply the body part as for the plaster jacket, moulding well over
the iliac rests. Apply plaster of Paris bandages as follows:
- a 10 cm bandage round the head and neck
- a 15 cm bandage over the shoulders in a figure of 8.
The following plaster of Paris slabs are applied and held in
position by 2 or 3 further bandages:
- 2 x 35 cm long and 20 cm wide, one for chin and top of chest
and one for occipital area and back of neck.
- 2 x 25 cm long and 20 cm wide, across the front and back of
shoulders.
- 1 x 55 cm long and 10 cm wide, for circumference of head.
- 2 x 10 cm long and 5 cm wide, for temporal area and front of

Minerva Jacket
PLASTER OF PARIS
Application
The cast should be well moulded round
chin and occiput, but should not put
pressure on the throat.

Minerva Jacket
SYNTHETIC CAST
Padding
Apply stockinette, fixing the body part to the head part with
non-allergic tape and also fix across the shoulders. Pad the
iliac crests and sacral area with non-adhesive felt squares.
Place the circle of gamgee over the diaphragm and 2 small
circles over the ears under the stockinette. The gamgee can
then be removed through abdominal and ear windows
during trimming. Apply a layer of undercast padding overall.
Place a piece of thin non-adhesive felt from the top of the
occiput to the T2 area of the spine and a second piece from
the tip of the chin down the neck to the top of the sternum.
Hold in place with a layer of padding.

Minerva Jacket
SYNTHETIC CAST
Application
Apply the body part as for a jacket, moulding well over the
iliac crests, except use I less bandage at this stage. Pad the
upper part and apply a 7.5 cm cast bandage around the
head and neck and a 10 cm over the shoulders and under
the axilla in a figure of 8. Cut and apply a slab of 3 layers x
7.5 cm to the front and back of the head and neck. Apply a
further 1 x 7.5 cm around the head and neck and 1 x 10 cm
over shoulders as before. Check the area in front of the ear
for strength. Complete the cast taking a 10 cm casting
bandage over the join of the upper and body part right down
to the iliac crest area. Apply this bandage firmly and cover
all with frimly applied wet crepe bandages. This should
assist bonding of the two pieces.
Do not take extreme care if using an electric oscillating saw
to trim or remove this jacket. The noise and vibration is most

Minerva Jacket

Shoulder Spica
* PLASTER OF PARIS
* Padding
* Application
* SYNTHETIC
* Padding
* Application

Shoulder Spica
A better fitting, more comfortable, cast can be applied if the
patient can sit or stand. If the cast is to be applied following
a shoulder operation, the trunk and lower two thirds of the
upper limb can be plastered 24-48 hours before the
operation. These two parts are then joined following the
operation while the patient is still anaesthetized. If the
patient is a buxom female, it is advisable to suggest that a
brassiere be worn to prevent excoriation of the skin beneath
the breasts.
The cast should extend from just below the iliac crests to
axilla on the unaffected side and on the affected side should
enclose the shoulder and the upper limb down to the palmar
crease and metacarpal heads.
As for the plaster jackets these casts must be well moulded
over the iliac crests so that no weight is taken on the
shoulder.

Shoulder Spica
PLASTER OF PARIS
Padding
As for plaster jacket and above elbow cast. Use extra layer
at the areas of the joins. A half roll of undercast padding is
placed in the axilla to prevent pressure there. Apply a semicircle of non-adhesive felt over the shoulder. Cover with a
layer of undercast padding.

Shoulder Spica
PLASTER OF PARIS
Application
The body part is applied as for a plaster jacket but trimmed
low under the axilla on the affected side. An above elbow
plaster to mid humerus is then applied. These two parts of
the cast are joined by using 15 cm plaster of Paris bandages
and 2 plaster of Paris slabs, 15 cm wide and 65 cm long, in a
figure of 8 around the arm and shoulder and on to the body
part. A 15 cm wide plaster of Paris slab is brought from the
iliac crest through the axilla and down the arm to just above
the elbow. This eliminates the need for a plaster bar from
the iliac crest to the forearm. Cover the slabs with a further
layer of 15 cm plaster of Paris bandage.

Shoulder Spica

Shoulder Spica
SYNTHETIC CAST
Padding
Apply stockinette, fixing the body part to the head part with
non-allergic tape and also fix across the shoulders. Pad the
iliac crests and sacral area. Place the circle of gamgee over
the diaphragm. The gamgee can then be removed through
the abdominal window during trimming. Pad the shoulder,
the olecranon and the medial epicondyle with non-adhesive
felt. Apply a layer of undercast padding overall.
The 2 mm adhesive felt could be used at the areas of the
joins for extra protection. A half roll of undercast padding is
placed in the axilla to prevent pressure there.

Shoulder Spica
SYNTHETIC CAST
Application
Apply following the instructions for a plaster jacket and the
above elbow cast finishing. The two parts are joined by using
10 cm casting material in a figure of 8 around the arm and
shoulder and onto the body part. Make a slab of 3 layers 10
cm x 50 cm long from a 10 cm casting bandage placing it
from the iliac crest through the axilla and down the arm to
just above the elbow and incorporate it between layers.
Complete the cast taking a 10 cm casting bandage over the
join of the upper and body part right down to the iliac crest
area. Apply this bandage firmly and cover all with firmly
applied wet crepe bandages. This should assist bonding of
the two pieces.

Shoulder Spica

Hip Spicas
* SINGLE HIP SPICA
* PLASTER OF PARIS
*Padding
*Application
* SYNTHETIC
*Padding
*Application
* ONE AND A HALF OR DOUBLE SPICA
* PLASTER OF PARIS
* SYNTHETIC

Hip Spicas
SINGLE HIP SPICA
These are generally applied with the patient lying on a hip
spica table with hip and knee slightly flexed. The hip is
abducted according to the medical officers wishes. Single
hip spicas can be applied whilst the patient is standing, if
their condition allows.
The cast extends from just below the nipple line to the pubis
anteriorly and fron the lower edges of the scapulae to the
coccyx posteriorly. It continues down the affected leg to end
at either the knee, ankle or to the toes.

Hip Spicas
SINGLE HIP SPICA
PLASTER OF PARIS
Padding
Stockinette is applied to the body with armholes cut like a
vest. The circle of gamgee is placed over the diaphragm,
and non-adhesive felt squares are placed over each iliac
crest and one down the spine over the sacral area. Apply a
layer of undercast padding around the hip and down the leg.
Use an extra layer around the supra-condylar area.

Hip Spicas
SINGLE HIP SPICA
PLASTER OF PARIS
Application
One layer of plaster of Paris bandage is followed by 2 plaster
of Paris slabs, each 1 to 1.5 meters long by 20 cm wide,
placed figure of 8 wise around the hip. (diagram 1 & 2) Two
reinforcing slabs, 45 cm long x 20 cm wide, are placed, one
anteriorly and one posteriorly, to the hip joint. (diagram 3 &
4) A further layer of bandages holds these slabs in place.
Mould well over the top of the iliac crests. If the spica is to
be a long single hip spica position the knee and pad and
plaster to the ankle, then position and complete down to the
foot.

Hip Spicas
Slabs for single hip spica

Single hip spica

Hip Spicas
SINGLE HIP SPICA
SYNTHETIC
Padding
Stockinette is applied to the body with armholes cut like a
vest. The circle of gamgee is placed over the diaphragm,
and non-adhesive felt squares are placed over each iliac
crest and one down the spine over the sacral area. Apply a
layer of undercast padding around the body and in a figure
of 8 around the hip and down the leg. Use an extra layer of
padding or 2 mm adhesive felt around the supra-condylar
area. It can be helpful to place a layer of thin felt on the
medial aspect of the proximal thigh.
This is an area where synthetic casting material can end up
being pulled tight.

Hip Spicas
SINGLE HIP SPICA
SYNTHETIC
Application
Apply the casting bandages round the body and in a figure
of 8 around the hip and down the leg to the knee. It is useful
to cut a 12.5 cm wide slab of 3 layers of cast material and
apply as the slab in diagram 1 on slide 175.
Sandwich the slab between the layers of casting material.
This slab will strengthen the triangle at the back of the hip.

Hip Spicas
ONE AND A HALF OR DOUBLE SPICA
For a one and a half or a double spica the patient is
positioned on the hip spica table as before and the
unaffected hip abducted to facilitate toilet care.
Pad as a single spica continuing the undercast padding down
both legs.
PLASTER OF PARIS
The 3 plaster of Paris slabs required are slightly different one slab being taken across the sacral area and anteriorly
over both hips. (diagram 1) The second and third slabs are
reversed, across the pubic area and round each hip, forming
a figure of 8 round the hips. (diagram 2 & 3) Great care must
be taken to ensure that the cast is strong over the posterior
aspect of the hip joints, the so called beginners triangle.

Hip Spicas
Slabs for one and a half or double spica

Hip Spicas
ONE AND A HALF OR DOUBLE SPICA
SYNTHETIC
When using synthetic materials use one slab made from 3
layers of 12.5 cm wide material as diagram 1.
A wooden or metal bar should be strutted between the legs
of one and a half or double spicas, and plastered on to the
outside of the cast once it has set. Pads of plaster of Paris
should be positioned under and over the bar ends before
plastering into position. This bar adds strength to the cast
and facilitates moving the patient, but must not be used for
such until the cast has finally set.
All patients who have large body casts applied must, of
course, receive full cast instructions prior to return home.
Comprehensive guidance on coping with daily living whilst in
such casts must also be given.

Hip Spicas
One and a Half Hip Spica

Double Hip Spica

Frog Type Casts

Padding
Apply stockinette 10 cm to the body, cutting laterally at the
hips, and 5 cm or 7.5 cm for the legs.
It is essential that the medical officer positions the legs for
this cast. With the anaesthetized child on a small hip spica
frame and the medical officer holding the legs in the
humane position, place a non-adhesive felt pad to the sacral
area and small felt strips to the flexed area of the hips. Apply
a firm layer of undercast padding.

Frog Type Casts

Application
Apply 4 rolls of 10 cm plaster bandages around the body and
the thighs and in a figure of 8 across the hips. Make sure to
check at the back as it is easy to miss the corners of the
sacral area. It must then be moulded well, helping it to
laminate. Once the bandages have initially set apply the
synthetic bandages to strengthen the cast in the same
technique as the plaster of Paris bandages. Check the cover
behind the hips again. Conform using a wet crepe bandage
remove as soon as the casting material has set.
The cast extends from just below the nipple line and can
finish either above the knees or is taken down to the ankle.
If the legs are to be included, place strips of felt around the
legs 2.5 cm above the malleoli and pad below the knee.
Extend the cast down to the ankle, taking care around the
flexor surfaces of the knees.

Frog Type Casts

Application
Trim the nursing area anteriorly to above the symphysis
pubis around the legs and posteriorly to just above the
coccyx. Use 2 mm adhesive felt to line the edges of the cast
as necessary and turn back the stockinette. Hold in place
with the 2.5 cm stretchy tape.
As well as the usual cast instructions the parents / guardians
need to have explained the extra care required. Use a
smaller size nappy, with a nappy liner if possible, tucked
inside the nursing area of the cast. Cover with a second
larger size nappy applied over the cast. The inside nappy
needs to be changed more frequently than normal to
prevent the cast becoming soiled.

Frog Type Casts

References
1. --------------, Clinical Knowledge: Fracture Management,
Training Material, GBU Orthopaedic, BSN medical
2. Johnson, Carl, Margaret Prior, John W Burden and Susan
Miles, A Practical Guide to Casting, 2nd edition, Casting &
Bandaging Global Business Unit: 2000