NON OPERATIVE

FRACTURE MANAGEMENT

SPLINT AND CAST

Dr.Said Osman Dahir, MBBS,MD
ORTHOPEDIC AND TRAUMA SURGEON.

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Fracture management
The ideal goal of fracture management is
anatomical reduction and function restoration
Either
Operative
Non operative (Conservative)
 Splint and Cast
 Traction

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Reduction
 Restorationof fracture fragment to acceptable position
 Aim for adequate apposition & normal alignment
 Two methods
 Conservative
 Closed reduction by manipulation
 Continuous traction
• Skin traction
• Skeletal traction
• Gravity
 Open reduction (operative)
 Under direct vision

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IMMOBILIZATION
Once the fracture is reduced, the clinician
may choose to immobilize the arm using
 Splint
 Cast
 Operative fixation

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 Joint position for immobilization
DIP 0-10 flex

PIP 0-10 flex

MCP 60-90 flex

Wrist 20-30 ext

Elbow 90 flex

Shoulder Abd & Internal ro

Knee 20-30 flex

Ankle Neutral

toes neutral

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 TREATING THE FRACTURE

Operative Non-operative

Rehabilitation Rapid Slow

Risk of joint stiffness Low Present
Risk of malunion Low Present
Risk of non-union Present Present
Speed of healing Slow Rapid
Risk of infection Present Low

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Splint / Cast
Principle:
◦ To stabilize joint above and joint below the
site of injury
Objectives:
◦ To hold broken bone anatomically to prevent
malunion
◦ To reduce excessive movements to prevent
non union
◦ To get early function

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BASIC PRINCIPLES OF SPLINTS
Expose the extremity completely before the splint is
applied
Remove ornaments
 Clean, repair, and dress skin lesions before applying
the splint
Immobilize the joints above and below the fracture .
Immobilize the bones above and below the
dislocated joint
Never splint fractures circumferentially, if the patient
has impaired sensation, excessive swelling, or
circulatory insufficiency
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Evaluate neurovascular status before and after application of
the splint
Make the plaster wide enough to cover one-half of the
circumference of the extremity.
Place Padding

◦ on the bony prominences

◦ between the digits to prevent maceration
◦ over the fracture site
Measure the plaster strips and cut or fold to length. Use
approximately 8 to 10 layers for an upper extremity splint
and 12 to 14 layers for a lower extremity splint
To prevent stiffness and loss of function, splint the involved
joints in their positions of function

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How to Preserve Function?
Immobilize only joint necessary
Range of motion of uninvolved joints.
Isometric exercise.
Physiotherapy after cast removal.
Weight bearing whenever possible in case
of lower limb fracture.

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Splinting Versus Casting

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Common Splinting Techniques
Sling and swathe splint
Velpeau bandage
Sugar-tong
Posterior slab
Ulnar gutter/ Radial gutter
Volar / Dorsal splint
Thumb spica
“Bulky” Jones

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UPPER EXTREMITY SPLINTS
1. Sling and swathe splint
For shoulder and humeral injuries

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2. Velpeau bandage
Used for shoulder and humeral injuries.
It is similar to the sling and swathe splint,
except that the hand is held higher and the
forearm lies against the chest

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3. Sugar tong splints
To treat humeral shaft, forearm, and wrist
fractures
 Proximal - Humeral fractures
 Distal - Wrist fractures, distal forearm
fractures
 Double - Elbow fractures, forearm
fractures

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4. Long arm splint(or posterior splint)  
 For stable injuries of the elbow area or forearm.
 Used also for temporarily stabilize intraarticular fractures of
the humerus, olecranon, or radial head in patients awaiting
surgical procedures
 From above the elbow to the midpalmar crease

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5. Colles splint
provide volar support
Use it for fractures of the second to fifth
metacarpals and distal forearm and wrist
fractures

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6. Dorsal and/or volar splint  
For carpal tunnel syndrome, soft tissue
injuries of the hand, and fractures or
injuries of the wrist.

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7. Gutter splint
Used primarily for phalangeal and
metacarpal fractures.
can be radial (immobilizing the index and
long fingers) or ulnar (immobilizing the
ring and little fingers, also called the boxer
splint).

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8. Thumb spica splint
Is a variation on the gutter splint.
Use it for scaphoid fractures and extra-articular
fractures of the thumb metacarpal or ulnar collateral
ligament injuries (i.e, gamekeeper's thumb)

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9. Bulky hand compression dressing
Used for closed hand fractures
provides bulky compression and
minimizes edema

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10. Figure-of-eight splint
middle two-thirds of the clavicle fractures

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11. Finger splints
Nondisplaced phalanx fractures
For Nondisplaced stable fractures of the
middle phalanx and proximal phalanx use
buddy taping the injured finger to an
adjacent finger

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LOWER EXTREMITY SPLINTS
1. Knee splint
usuallyused for acute knee injuries including
Contusions/sprains ,Patella fractures , and
Ligamentous tears
Function: Immobilization and
Support

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2. Posterior leg splint
Used for distal leg, ankle, tarsal, and
metatarsal fractures, reduced dislocations,
and severe sprains

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3. Ankle stirrup splint
Also called the ankle sugar tong splint
To prevent inversion or eversion of the
ankle
Provide better immobilization than the
posterior leg splint for fractures near the
ankle

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4. Bulky foot compression dressing
Use it to treat calcaneal fractures and foot
injuries.

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5. Buddy taping
For phalangeal fractures of the toes.

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 CAST
A standard treatment for many closed,
nondisplaced, or reduced fractures
The optimal time to place a cast is after post-
traumatic swelling has resolved.
Most often a splint is used in the interim.
Successful casting requires three things:
proper materials, proper positioning, and
selection and application of the appropriate
type of cast.

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 What are casts made of ?
The outside, or hard part of the cast

 Two different kinds of casting materials.

◦ Plaster (POP) - white in color.
◦ fiberglass - variety of colors, patterns, and designs.
Inside of the cast
 Cotton and other synthetic materials are used to
line the inside of the cast to make it soft and to
provide padding around bony areas.

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Plaster is usually used in the early stages of
treatment,
◦ Displaced Fracture that need manipulation
◦ can be molded more precisely.
◦ heavy
◦ must remain dry, water will distort the cast 
 Fiberglass
◦ Can be used in Undisplaced Fx if swelling not expected
◦ lighter weight, durable, require less maintenance.

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 Comparison
Plaster Fiberglass
 Longer drying time  Shorter drying time
 more prone to indentations  lighter
that can lead to breakdown  more resistant to dirt
 stronger  more durable
 heavier  more costly
 less costly

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General Indications for CAST
1. Most fractures in children:
a. Tremendous capacity of remodeling.
b. Non union and stiffness is unlikely.
2. Undisplaced fracture
3. Poor bone Quality: Osteoporosis.
4. Unfixable fracture e.g. severe comminuted.
5. Systemic contraindication.
6. Local contraindication.
7. Psychosocial problem.

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Plaster of Paris
Naturally occurring substance derived from gypsum
When gypsum heated to 128 C, water evaporates
leaving plaster of Paris
Plaster of Paris is a hemi hydrated calcium sulphate.
2(Caso4 2H2O) +Heat 2(Caso4 1/2 H2O) + 3H2O
When water added to dry plaster of Paris, molecules
are added to gypsum producing a hard cast.

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 POP cast
Here the POP completely encircles the limb.
◦ It is used as a definitive form of fracture treatment and also to correct
deformities.
There are three methods of applying a POP cast.
◦ Skin tight cast:
 Here the cast is directly applied over the skin. Dangerous as it may cause
pressure sores. It is difficult to remove as the hairs may be incorporated into
the cast and hence it is not recommended
◦ Bologna cast:
 Here generous amount of cotton padding is applied to the limb before putting
the cast. This is the commonly employed method
◦ Three tier cast:
 Here stockinette is used first, over which cotton padding is done before
applying the POP cast. It is an ideal method

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Materials
Cotton pads
Plaster bandage
Stockinet
Water
Scissor

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 Casting Equipment

Stockinet
Stockinet Padding Casting Tape
Padding
Glove
Gloves Casting Tape
s
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Tubular stockinet is used to line and trim the
end of casts, and it has many other uses. It is
available in widths from 2 to 12 inches.

Sheet cotton for padding casts comes in rolls in

widths of 2, 3, 4, and 6 inches.

Commercial plaster of Paris rolls are available

in widths of 2, 3, 4, 5, 6, and 8 inches.

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Cast Application Guidelines
Protect floor with newspaper or plastic
Protect pt’s face, clothes & skin with
towels
Fill bucket with water
clean & dry skin thoroughly
Test and document skin condition,
circulation, & sensation prior to making
cast
wear plastic gloves

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Casting Techniques
Stockinette - may require 2 different sizes to
avoid over tight or loose coverage

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Padding - distal to proximal with 50%
overlap
◦ extra padding at fibular head, malleoli,
patella, and olecranon
◦ Apply 1 layer of cotton padding in spiral
fashion with ½ overlapping layers in figure
8 over elbow or knee
◦ add 2-3 more layers of cotton padding
◦ apply padding 1-2 inc longer than both ends
of cast
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Dip plaster and slightly wring water out
(hold ends or crimp for ease of use)
◦ dip 5-6 times until it bubbles
◦ don’t remove too much water
Apply 4-5 layers of plaster
◦ just slightly overlapping
◦ smooth in a circular motion between layers

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Avoid pressing fingers or holding on one spot
of the cast for prolonged periods
Use a flat hand technique to avoid finger
impressions
Before last layer, pull stockinet out and turn
down onto the cast. Apply casting tape just
below this edge to create a smooth soft edge
Hold cast in correct position until it dries

N.B:
o Improper casting can cause neuropathies
o Casting too tightly can cause edema

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Different types of casts
Type of Cast Location Uses

Short arm Applied below the elbow Distal Forearm or wrist

to the hand. Fx. Also used to hold the
forearm or wrist muscles
and tendons in place after
surgery.
Long arm Applied from the upper Distal humerus, elbow, or
arm to the hand. proximal forearm
fractures. Also used to
hold the arm or elbow
muscles and tendons in
place after surgery.
Scaphoid cast/ thumb Below elbow to hand Scaphoid Fx, thumb FX
spica including thumb

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Hanging arm cast
Dependency traction provided by the
weight of the cast
To be effective, the patient must remain
upright or semi-erect at all times
Concern – fracture distraction resulting in
delayed union
Indications
◦ displaced midshaft humeral shaft fractures
with shortening (oblique or spiral pattern)
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Type of Cast Location Uses

Short leg cast: Applied to the area below Distal T/F Fx,
the knee to the foot. ankle Fx,
severe ankle
sprains/strains.

Long leg cast From above knee to foot Proximal T/F Fx,
trauma around knee

Hip spica From lower chest to one Femur fracture in

or both feet children

PTB cast From knee to foot For weight bearing in

healing Fx T/F

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SHORT LEG CAST/BELOW KNEE
CAST
Most commonly used cast for lower limb injurie
Landmarks:
◦ Distally: head of metatarsals.
◦ Proximally:just below tibial
tuberosity anteriorly and three
finger breadth distal to popliteal fossa.

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LONG LEG CAST

◦ Immobilize by a cast from the web space of the toes to 4

inches distal to the groin(on the medial side)& flared 1
inch proximal to the greater trochanter on the lateral side

◦ Ankle dorsiflexed 90° – absence of inversion or

eversion, with toes having full range of motion

◦ Knee flexed

◦ Good peripheral circulation

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INDICATIONS
Diaphyseal & proximal tibial fractures

Supracondylar femoral fractures

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Patellar Tendon Bearing Cast/PTB
Isa variant of short leg cast.
Indication:
◦ Tibial Diaphyseal fracture after few weeks of LLC.
 1 week…. Long leg posterior slab.
 5 weeks….long leg cast
 6 weeks ….PTB.
◦ Rehabilitation of the knee
Proximal end of below knee cast is extended
up to level of lower pole of patella and molded
around patellar tendon.
Advantage:
◦ Provide rotational stability & flexion of knee up to
90⁰.
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NB:care must be given not to apply pressure over the
common peroneal nerve which running
around the fibular neck.

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SPICA CAST
Spica Cast- includes the trunk of the body and one
or more limbs
Hip Spica – includes the trunk of the body and one
or both legs
Shoulder Spica - includes the trunk of the body
and one arm, usually to the wrist or hand

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Shoulder spica
 Are almost never seen today, having been replaced with
specialized splints and slings
 It is a complex method of immobilization and requires
close follow-up.

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HIP SPICA
INDICATIONS
◦ Femoral shaft fractures in young children (6 months - 5 years)
◦ Adjunctive stabilization of pediatric hip fractures after cannulated
screw fixation
◦ Maintenance of closed or open reduction of DDH (Usually children 6
months – 2 years)
◦ Adjunctive stabilization of acetabular or proximal femoral osteotomies
◦ Immobilization after an unstable reduction of posterior hip dislocation
◦ Following drainage of a septic hip

CONTRAINDICATIONS
◦ Unacceptable shortening or angulation
◦ Open fracture
◦ Thoracic or intra – abdominal trauma

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Long-leg hip spicas

A: One and one-half

spica.
B: Double spica
C&D: Single spica

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 After Closed Reduction and Casting
must have circulation check
Plaster takes 48 hours to become fully dry
and harden so take care.
Weekly radiographs for 3 weeks to confirm
acceptable reduction.
Can re-manipulate within 3 weeks after injury
if displaced.

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 Post Cast instructions
 Keep your limb elevated to prevent swelling.
 Apply an ice bag to injured area.
 Keep the cast clean and dry.
 Check for cracks or breaks in the cast.
 Rough edges should be padded to protect the skin from
scratches.
 Do not scratch the skin under the cast by inserting sticks.
 Encourage patient to move his/her fingers or toes to promote
circulation
 Prevent small toys or objects from being put inside the cast.
 Do not put powders or lotion inside the cast.

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 How To Know if Something Is Wrong With Your Cast

 Pain that is not adequately controlled with medication

 Increasing swelling
 Numbness or tingling in the extremity (hand or foot).
 Inability to move your fingers or toes beyond the cast.
 Circulation problems in your hand or foot.
 Loosening, splitting or breaking of the cast.
 Unusual odors
 If you develop a fever or generalized illness

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 Complications of cast
Compartment syndrome(Pain with passive
stretch, Pain out of proportion, Paresthesia,
Paralysis , Pulselessness, pallor)
Impaired distal neurovascular structures.
most serious is deep venous thrombosis leading to
pulmonary embolism----calf pain.
Re-displacement of fracture.
stiff joints, muscle wasting.
Plaster Sores
Malunion, Nonunion, Delayed union

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Complications of casts/splints
Loss of reduction
Pressure necrosis - as fast as 2 hrs
Tight cast/compartment syndrome -
univalving = 30% pressure drop
bivalving = 60% pressure drop

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 Monitor Cast
q 2 hours for first 24 hours
Pain
Edema
Sensory changes
Circulatory Changes - check pulse points distally
Increase or Decrease movement in cast
Severe itching
Cracks, dents, or softening of cast
Pt’s with communication difficulties may not
be able to express pain or problems
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Care of Cast
Don’t get it wet
Cover with plastic bag if bathing
Don’t weight bear for 24 hours to allow
cast to harden

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When an open wound requires care and is associated with a
fracture to the extremity that must be casted, the following is a
good technique for knowing where to cut a window in the cast
for wound care and observation. A. The wound is covered with
sterile dressings, which are wadded up in a ball over the wound.
B. The cast is then applied in the routine fashion over the dressed
wound. C. A window is cut out over the "bulge" produced in the
cast.
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 Cast removal
Always use a sharp blade
kept blade perpendicular
to cast surface
Press cast saw all the way
through one site at a time
Spread cast with spreaders
Cut padding and stockinet
with bandage scissors

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Cast removal using (A) cast saw and (B) cast spreader and safety bandage scissor
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 REFERENCES
Rockwood and Green′s Fractures
Emergency orthopedics
Practical Fracture Treatment
Up to date 21.3

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