Casts for Children’s Fractures
Predictable application and maintenance of complication-free casts in children is a slowly learned art and craft. In contrast to adult patients, in whom immobilization may produce osteopenia and joint stiffness, children rarely suffer long-term effects from typical periods of cast immobilization. Instead, children have a special set of complications, including poor application, poor fit, and loose casts that slide off. Physicians often fail to understand the effect that the carefree personality of a child has on the life, durability, and function of a cast. Also, children often do not complain if a cast is tight or irregular (producing ulcerations) with the damage noted only when the cast is removed.
This chapter is intended to present general principles for safe, predictable cast application for fractures in children, and to demonstrate the many techniques we have developed at Rady Children’s Hospital, San Diego, to make the use of synthetic cast materials safe and predictable. Most of the principles also apply to plaster of Paris casts.
“Show me your cast and I’ll tell you what kind of orthopedist you are”
Casting in Children’s Orthopedics
This lovely photograph, taken in front of the Hospital for Sick Children (Toronto) in about 1915, demonstrates a child in corrective casts for clubfoot, attended to by her nurse. (Reproduced courtesy of Mercer Rang.)
Immobilization for fracture treatment can be traced to antiquity. Traditional methods included use of (a) muslin reinforced with egg whites or starches and (b) soft wood splints. Plaster of Paris was first used in the late 18th century by the Turks to immobilize limb fractures. The limb was placed in a box that was then filled with plaster—an awkward, bulky process.
Military surgeons were the first to push for less cumbersome methods of fracture immobilization, and Mathijsen was credited with the first use of plaster of Paris dressings in 1852. In his process, the plaster of Paris was applied to muslin or linen cloth so that the resulting “plaster dressing” could be rolled onto the limb. This tedious process of rubbing the plaster into the muslin or linen was done manually, just prior to application, by the surgeon or his assistant, and continued until about 80 years ago.
Ready-to-use manufactured rolls of plaster of Paris were not commonly available until the mid-20th century. In the late 20th century (1980-2000), the use of synthetic casting materials (fiberglass) gradually replaced plaster of Paris in developed countries. Because synthetic materials are more expensive, plaster of Paris casts remain common in much of the world.
Anthonius Mathijsen (1805-1878), a Flemish army surgeon, was the first to use plaster of Paris impregnated in rolls of linen cloth that could be rolled onto the limb. In his first publication in 1852, he noted that his special bandages hardened rapidly, provided an exact fit to maintain reduction, and could be easily windowed or bivalved.
Plaster of Paris has clearly been the standard material for cast construction over the last 150 years. Exponential improvement in the texture, “rollability,” and “moldability” of synthetic materials has made them the cast material of choice for most modern orthopedic surgeons. Patients like them because they are light-weight and durable. We now use synthetics for all pediatric orthopedic casts, except for serial corrective foot casts used to treat clubfoot (Ponseti casts). However, some orthopedists still prefer the moldability of traditional plaster of Paris for reducing and maintaining acute fractures.
Casting Materials Timeline
From the beginning of time, sticks and mud and cloth have been used to stop fractures from moving about. We have knowledge only of recent events.
400 BCE Hippocrates describes splints.
970 CE In Persia, Muwaffak advises coating fractures with plaster.
1740 As a child, Cheselden (Britain) has a fracture treated by a bonesetter with bandages dipped in egg white and starch. When Cheselden becomes a surgeon, he introduces the method for his patients. The bandages take a day to harden.
1799 A visiting diplomat reports that he saw a Turkish patient treated by holding the injured limb in a box that was then filled with plaster. He tried to interest European doctors in the method. The cast was big and heavy and prevented ambulation.
1814 Pieter Hendricks uses plaster bandages—but the idea does not catch on.
1824 Dominique Larrey, Napoleon’s surgeon, uses egg white and lead powder.
1835 Louis Seutin: Starch bandages.
1852 Antonius Mathijsen introduces plaster bandages in a medical book and has a friend who popularizes it. Soon, large numbers of people are putting plaster into bandages. Until the 1950s, it was a job for medical students on emergency call. Then machines led to commercial manufacture.
1903 Hoffa’s belief that “the plaster bandage will remain the essence of orthopedics for all time” seems to be going the way of all predictions.
1970 to present Development and widespread use of synthetic materials for casts.
Plaster did not enjoy universal popularity. Complete casts on fresh fractures can produce dreadful complications, and this led some influential leaders to ban casts. Thomas and Jones in Britain and Knight, founder of the first residency program in the United States, would have nothing to do with plaster, and Knight fired one member of his staff for promoting its use.
Courtesy of Mercer Rang
Plaster of Paris (Gypsum—CaSO4)
Plaster was first used in approximately 7000 BCE by ancient Egyptian, Greek, and Roman civilizations. It took on the name “Plaster of Paris” in the late 1600s following “The Great Fire of London” in 1666. In an attempt to mitigate against the devastation that London suffered, the King of France ordered that all Parisian walls made of wood be covered with plaster. This led to large-scale gypsum mining in and around Paris (where the material was abundant). When the walls in Paris were sufficiently covered, Parisians began exporting the substance, which became known around the world as “Plaster of Paris.”
Photo by Zinneke (Own work) [CC BY-SA 3.0 (creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons
Although synthetic cast materials are more expensive than plaster of Paris, in assessing overall expense one must consider the costs in time, labor, materials, and repetitive visits to cast rooms by children who have inadvertently soaked or damaged a plaster cast.
Duration of Treatment
The issue of when and for how long cast immobilization should be used for fracture treatment has been historically controversial. Hugh Owen Thomas (prolonged immobilization) and Lucas-Championniére (early motion) developed diametrically opposing views in the late 19th century (see Chapter 2). The controversy remains, but less for children’s fractures, where post-casting joint stiffness is rare and re-fracture after early cast removal is common. We tend to cast longer.
GENERAL PRINCIPLES OF CAST APPLICATION
A great variety of cast types are used in children (body jackets, hip spicas, extremity fracture casts), and we will not attempt to describe them all. Instead our focus will be on general principles of cast immobilization of extremity fractures, including hip spica casts (Figs. 5-1, 5-2).
Basic principles should be considered. For small children, you must decide who can best hold the child’s arm or leg while the cast is applied. Although parents can assist, most casts are better applied with a trained medical assistant holding the limb. Special foot-holding stands designed to keep the ankle at a neutral position can be useful for adolescents and adults but are of little help in a young child.
Several steps increase your chances for a well-fitting cast. Whether or not stockinette should be used on the skin prior to cast padding application (Fig. 5-3) depends on where and for what reason the cast is being applied. For elective casts applied in an office or an outpatient clinic, use of stockinette decreases “bunching” of cast padding, allows a neat-appearing cast, stops the rough edge of the cast from abrading the skin, and makes cast removal easier and perhaps safer (less chance for cast-saw cuts or burns).
In postoperative casts applied in the operating room, the presence of surgical dressings, suction drains, percutaneous pins, etc., makes stockinette use more difficult. Also, with difficult manipulative reductions performed in the office or clinic, application of stockinette is often an added step that impedes efficient, rapid application and molding of the cast. A compromise is to use a short segment of stockinette (perhaps 6 in. long) at the proximal and distal end of the cast (which will leave the carefully placed surgical dressing sponges undisturbed).
Other cast application accessories include using a 2-3 in. wide band of felt padding proximally in the thigh, arm (humerus), or proximal calf, which provides comfort and decreases skin irritation (Fig. 5-4). In spica casts for thin children, we often use both (a) a complete layer of felt and (b) adhesive-backed foam padding for bony prominences (iliac crest, greater trochanter, and sacrum).
We advise that almost all casts applied in the operating room be immediately split (uni-valved) while the child is still anesthetized to decrease the discomfort, aggravation, and fright involved in late-night cast splitting in the patient’s room (or in the ER during an emergent return owing to swelling). This is particularly important in a children’s hospital, where the parents are often in the room with the child (and will suffer, along with their child, from the noise of a cast saw).
Figure 5-4 Felt at the junction (when the cast is applied in 2 parts) makes the transition safer. Felt at the end of the cast (proximal) makes it more comfortable.
Rolling the Cast
Efficient rolling of the plaster or synthetic material requires experience. Appropriate rolling technique, including the placement of tucks to allow smooth wrapping over a conical structure, is a slowly learned art. This is most important for plaster casts in which the material will not stretch. Orthopedic residents need instruction in this art, followed by supervised practice. Often their opportunities for learning are blunted by the current trend toward having orthopedic technicians apply most casts in many training hospitals. The sad tradition of lumpy, formless, inefficient casts applied at “Elsewhere General” continues, applied by both inadequately trained surgeons and technicians.
Great care must be taken to avoid making casts too tight. This is a particular problem with synthetic-material casts: They are often wrapped in the same manner that one applies an elastic (Ace) bandage, with stretching to accommodate limb shape change rather than placing tucks (which makes the cast less tight). This is possible because the underlying “cloth” is stretchable (in contrast to the “stiff” muslin in plaster of Paris). The result is a cast that is often too tight, particularly when applied in the operating room following surgery. In circumstances where any swelling whatsoever is anticipated, synthetic cast materials should be applied with tucks, just as would be done with ordinary plaster. This makes a less restrictive cast.
Casts in the operating room should be applied after the tourniquet has been deflated to normalize limb volume (by allowing the blood to return to the limb). The cast is then applied loosely, using the tuck technique. Then in most cases the cast should be immediately split to allow further swelling, with the cast re-tightened 3-7 days later.
The Disappearing Toe Syndrome
The call is classic in children’s orthopedics—“My child’s toes are disappearing.” Disappearing toes mean the poorly fitted cast is allowing the foot to pull up the cast. A skin ulcer will soon follow. In this case, there was an ulcer on the heel and on the dorsum of the foot.
Proper cast molding assures good cast fit, thereby decreasing the chance for cast sores (Fig. 5-5). A cast should fit the limb contours and be thought of in the sculpting sense; that is, if the cast were removed and filled with plaster or wax, the result would be a “casting” identical to the patient’s limb. Careful molding around bony prominences is required to achieve excellent fit. The calcaneus is at great risk in the lower extremities; the molding must be focused on the soft tissues above the tip of the calcaneus, leaving a recess for the heel prominence. If you fail to provide this recess, a skin ulceration over the posterior calcaneus is a near certainty in a vigorous child.
The concept of a well-molded cast contrasts with the terminology of applying a “plaster dressing” after surgery. Many surgeons prefer a bulky “Robert Jones” dressing after surgery, followed by application of a well-molded cast once the swelling has subsided. We rarely do this in children because we can achieve the same effect applying the cast in the operating room and splitting and spreading the cast immediately postoperatively, with later tightening. This avoids post-operative cast changes, which children detest.
Cast edge trimming is time-consuming, but it can be avoided by careful planning when the cast material is rolled. For instance, at the distal end of a leg cast, the plaster should be rolled at a 30 degrees angle, keeping the lateral side short so that subsequent trimming in the area of the fifth toe and metatarsal head are not required. We perhaps exaggerate by stating that no cast should ever have a final “transverse end.” Whether in the foot, the popliteal fossa, the groin, or the proximal humeral area, casts predictably immobilize better, require less trimming, and fit better if they end obliquely. Learning to wrap casts with oblique ends greatly decreases the labor required to trim and finalize the cast. By avoiding trimming, few sharp edges remain (a particular problem with synthetic cast material).
CAST SPLITTING AND REMOVAL
Cast Splitting (Bivalve, Univalve)
Traditional training suggested that any cast requiring splitting be split completely to the skin, including the cast padding. We have no argument with the “always split to the skin” philosophy for hospitals with little supervision of patients casted following fracture reduction or operations. An edict issued by the “commanding officer” to split all casts to the skin is likely the best insurance against cast complications, compartment syndromes, etc., in these circumstances. Although some
orthopedists prefer a bivalve (double) split in all casts, with the use of spacers to maintain the separation, we have been able to use single splits in most cases—including synthetic casts (Fig. 5-6).
orthopedists prefer a bivalve (double) split in all casts, with the use of spacers to maintain the separation, we have been able to use single splits in most cases—including synthetic casts (Fig. 5-6).
Figure 5-5 An example of a thin, well molded cast. Note that the length along the ulnar border is longer than the opposite side.
Although some insist on “always split to the skin” or “always bivalve,” we advise a more refined approach for an orthopedic office, or in a high-quality teaching hospital that provides close patient monitoring. This can be safe, economical, and, most importantly, less distressing to children.
Synthetic-material casts require special methods because even though the cast is split longitudinally (univalved), the resilience of the material will not allow the cast to stay separated. Special commercially available spacers are needed.
Graded splitting of casts following fracture reduction or orthopedic operations requires good orthopedic judgment. Limited splitting can provide great economic advantage to the hospital and surgeon without placing the patient at increased risk. Our policy of graded splitting according to risk is as follows:
Level 1. Only modest swelling anticipated (e.g., following simple limb surgery or reduction of simple distal radius fracture). Level 1 splitting includes a single longitudinal split in the cast, combined with spreading and placing a spacer but without cutting the underlying cast padding. In our children’s hospital environment, 95% of cast splits are level 1. This percentage must be interpreted within the context that we split nearly all postoperative casts and most fracture reduction casts.
Note that synthetic cast splits will not remain open unless spacers are placed. Several manufacturers produce small plastic spacers of varying sizes that are inserted to keep the cast separated. These are removed in 4-7 days after swelling has subsided, with the cast then tightened with tape (upper limb), or another roll of cast material (lower limb).
TECHNIQUE TIPS: Graded Cast Splitting According to Risk Severity
Level 1: Cast split dorsally; soft-roll and underlying dressing not disrupted. For routine postoperative cases and simple fractures. A spacer must be placed to hold the cast open.
Level 2: Both cast material and underlying soft-roll split to skin. For more serious cases of swelling.
Level 3: Cast split medially and laterally, with soft-roll cut down to skin. Allows removal of entire anterior half of cast for inspection of skin and for palpation of compartments.
Level 2. For children with significant swelling anticipated (e.g., fracture with potential for vascular problems; postoperative triple arthrodesis; other similar cases). The single longitudinal split includes both the cast material and the underlying cast padding down to the skin, allowing wide spreading of the cast. Once the cast padding has been split, window edema can develop; therefore, thin strips of cast padding should be packed longitudinally into the split and should be over-wrapped with an elastic bandage. A cast with a level 2 split can still be repaired (pulled together) once swelling has subsided, although care must be taken to avoid “bunching” of the cast padding (we rarely perform a level 2 split—most are level 1, a few level 3).
Level 3. Used for cases with marked swelling anticipated (e.g., tibial fracture in which compartment syndrome is suspected). This includes a medial and lateral complete split of both the cast material and the underlying cast padding down to the skin. The anterior panel of the cast can then be removed for complete inspection of the limb and palpation of the compartments.
Figure 5-7 Stille cast shears. Developing skills with this instrument allows you to avoid noisy cast saws when removing certain casts. However, they work better for plaster than for synthetic materials.
Figure 5-8 Proper technique is required to use a cast saw. Usually the thumb is held against the cast and the blade itself is pushed in an “up and down” fashion against the cast material without dragging the saw longitudinally.
Cast removal remains an often traumatic event for a child. Potential complications can be minimized with continued education. Shore et al. identified three primary risk factors for cast saw injuries when removing a cast: provider inexperience, patient sedation, and poor cast blade condition. Although somewhat obvious, quality, dedicated training in regard to the application and removal of casts as well as rigorous maintenance of cast removal equipment is the first line of defense in preventing cast saw cuts and burns.
A variety of methods/techniques can make cast removal easier and safer. Traditional cast shears can be used for small plaster casts (Fig. 5-7). Current cast-removal saws are loud, aggressive, somewhat terrifying to children. No amount of conversation or playful application of the vibrating cast blade to one’s own hand to demonstrate that it “won’t cut” will placate a properly suspicious child.
Orthopedic technicians and orthopedists who deal with children can apply many special techniques to minimize cast-removal trauma. Empathy is the first step. All orthopedic residents and fellows should have a synthetic-material cast applied on their own limb and then removed by a fellow resident (see how they jump!). This greatly increases sensitivity for the child’s plight. We do a cast application-removal session with each new group of residents and fellows when they rotate through our hospital.
The correct mechanics of cast-saw use must be mastered. Techniques include placing the thumb and/or fingers on the cast as a stabilizing guide, with careful reciprocal “up and down” movement (Fig. 5-8) rather than long dragging movements of the blade along the cast increases the risk for skin injury (cut or burn). Also avoid using the cast saw over bony prominences (medial malleolus, etc.). Also pull the cast away from the skin as you begin the cut.