Practical Guide to

Casting

Author: Matthew Pitt

Senior Orthopaedic Practitioner
 General Anatomy
Locomotor System :
The locomotor systems are those which enable a person to move about, change
position, hold articles and handle tools.
They are:
• The Skeletal System of bones and Joints
• The Muscular System
• The Nervous System
The Skeletal System

The Skeletal System is formed of the bones

of the skeleton, symmetrically arranged. It
is divided into:

• Appendicular skeleton, comprises the

bones of the upper limb and shoulder
girdle clavicle and scapula and the
lower limb pelvic girdle

• The Axial skeleton, comprising bones of

the trunk and head.

The skeleton has the following

functions:
• It forms the framework of the body
• It is arranged to give protection to
vulnerable tissues, e.g brain, lungs,
heart, spinal cord
• It gives attachment for muscles which
bring about movement or maintain
posture.
• It takes part in the formation of joints
• It supports and maintains posture of the
body
• It is concerned with the use of the
calcium in the body and formation of
various blood cells
 General Anatomy

Structure of Bone
Bone is formed of protein substances,
33% of which is collagen and minerals
and salts, primarily calcium phosphate
and carbonate, which together make it both
strong and resilient. Bone integrity is
Maintained by bone cells, osteoblasts or
Bone builders and osteoclasts bone consumers.
It is a balance between osteoblastic and
osteoclastic activity that ensures healthy strong
bone. The surface layer, or compact bone, is
smooth and rigid and gives the individual bone its
strength.

Joints are sites where two or more bones meet. They are classified as fibrous, cartilaginous or
Synovial joints according to the substance separating the bones within the joint. Of most interest
to the Plaster Room staff will be synovial joints because they are mostly freely-movable and
hence disease prone.
 General Anatomy
Synovial Joints
Single Hinge Joint

Usually comprises two bones

and moves in one plane, e.g.
elbow joint or ankle
The articulating bone surfaces are smooth
and covered with articular cartilage. In healthy
joints, the two surfaces of cartilage are in contact
with each other and are lubricated by a thin film of
synovial fluid. Synovial fluid nourishes and
Composite Hinge or Condyloid Joint
lubricates the intra-articular surfaces. A sleeve of
strong fibrous tissue – the capsule – holds the
two bones together and surrounds the joint

Ball and Socket Joint

Two bones capable of moving in

More then one plane, e.g. wrist

Rounded head on bone fits into a

cup shaped cavity on articulating
bone, e.g. hip joint or shoulder
 General Anatomy
The Muscular System
The principle characteristics of skeletal muscle are
contraction (shortening) and extension (lengthening). A
muscle consists of the belly or fleshy part of the muscle
and usually a tendon for attachment to bone. The muscle
must cross a joint in order to bring movement of that
particular joint.
Extension of one muscle is usually brought about by
contraction of its opposing muscle. This is the simple
basis of movement for example, if you flex the elbow
joint by contracting biceps brachii and brachialis, the
triceps, their antagonist will extend.

Nervous system of the arm

Peripheral nerves which lie close to the surface are vulnerable especially to
the application of casts and splints. This can result in temporary or
permanent disability, especially the ulnar nerve, radial nerve and median
nerve after applying a Below elbow or above elbow casts.
 Terminology

• The Root of a word can comprise any part of a word, but always has the
same meaning

• A Prefix is the opening group of letters in a word that direct its meaning

• A Suffix is the closing group of letters in a word that direct its meaning

Root Meaning Example(s)

Arthro- Joint Arthritis

Chondro- Cartilage Chondroma

Haem Blood Haemarthritis

Osteo Bone Osteoarthritis

Patho Disease Pathology

Myo Muscle Myositis ossificans

Cyst Sac Bone cyst

Ped/pes Foot Pes planus/talipes

 Terminology
Prefixes Meaning Example(s)

Ab Away from Abduction

Ad Towards Adduction

Bi Two Bilateral / Bi-Valve

Epi On or Upon Epicondyle

Intra Within Intravenous

Infra Below Infraspinatus

Pseud False Pseudarthritis

Sub Under Subperiosteum

Supra Above Supracondylar

Suffixes Meaning Example(s)

-algia Pain Neuralgia

-osis Condition/disease Neurosis

-desis Surgical Stiffening Arthrodesis

-ectomy To remove / excision Appendectomy

-itis Inflammation of Arthritis

-oma Tumour Myeloma / Sarcoma

-plasia Develop/formation Achondroplasia

-tomy Cutting into Osteotomy

 Anatomical Position
• The Anatomical position = the subject in the upright position facing the observer
with feet flat on the floor, arms by the side, palms facing forward

Anterior To the front

Posterior (dorsal) To the back

Proximal Nearest to the trunk

Distal Farthest away from the trunk

Superior Above
Inferior Below

Medial Part nearest to the midline

Lateral Part farthest away from midline

Plantigrade Planti-grade- position of foot

when standing with sole & heel
touching the ground

Optimum Best possible position in the

circumstances

Valgus The distal part of the bone is bent

or twisted away from the midline
of the body.

Varus The distal part of the bone is bent

or twisted towards the midline of
the body.
 Movements at Synovial Joints
Flexion Decrease in the angle between the surfaces of articulating
bone
Extension Increase in the angle between the surfaces of articulating bone

Hyperextension Continuation of extension beyond the anatomical position

Abduction Movement away from the midline

Adduction Movement towards the midline

Circumduction Combination of flexion/extension/abduction/adduction in

succession to produce the circular movement of the distal end
Inversion Movement of the soles of the feet inwards so they face each other

Eversion Movement of the soles of the feet so that they face away from
each other
Dorsiflexion Movement of the foot/hand upwards in the direction of the dorsum
(upper surface)
Plantarflexion Movement of the foot downwards in the direction of the plantar
(sole) surface. Sometimes referred to as Equinus
Palmarflexion Flexion of the wrist so the palm is towards the forearm

Supination Movement of the forearm in which the palm is turned anteriorly or

upwards (palm to sun)
Pronation Movement of the forearm in which the palm is turned posteriorly
or downwards
Opposition Opposing i.e. when the thumb is adducted to oppose the fingers
 Fractures
A fracture is defined as a ‘break in the continuity of a bone’. In layman’s terms a
fracture is a break, and break is a fracture. Often the bone is broken completely across,
occasionally, the break is only one side of the bone, and we may describe such a fracture
to the patient as “greenstick fracture”. These incomplete greenstick often occur in children.

Spiral fracture

Oblique fracture

Transverse Fracture
 Basic Rules of Casting
Application of casts:
In order to apply an effective cast the practitioner should check the manufacturer’s
instructions/recommendations for the application of their specific product.

Stockinette:
Is widely used to provide comfortable lining for casts but it need not be used if swelling is
expected, for example following manipulation, new injuries or if its application would cause
undue pain.

Padding:
Natural or synthetic materials should be chosen with the holistic needs of the patient in mind
and it should be applied evenly. One layer should be sufficient with a 50/50 overlap, too much
padding can cause additional problems e.g. rucking of fabric or a loose cast. Special
attention should be made to bony prominences and orthopaedic felt should be used to off-load
pressure.

Crepe Bandage:
The appropriate size crepe bandage should be chosen and submerged into the water prior to
application of any of the plaster of paris slab. By wetting the bandage you create a stronger
bond making the slab stronger and preventing loose bandaging which can come off when
clothes are taken on and off.

Plaster of Paris Bandages / Slab:

Should be dipped in water according to the manufacturers recommendations. The water should
be cool to tepid. Very cold water will slow the setting process and very hot water can potentially
burn the patient. All casting materials create their own heat (exothermic reaction) as they
set/dry.
Firstly choose the desired width required to adequately immobilise (support) the limb. Roll out
your plaster of paris bandage creating a 6 to 8 layer slab. When placing onto the limb gently
mould to conform it correctly and smooth it out, do not press or pinch in as this could create a
pressure area. Turn back the stockinette if used, catching it in the last layer of bandage. Be
careful not to pull the casting bandage back with the stockinette as this will create a crease at
the edge. Hold the casted limb in the desired position until set, then rest on a pillow. Any further
trimming can now be done to expose joints not requiring immobilisation. The drying time is
between 24-48 hours depending on thickness.
 Basic Rules
Care of the patient: Check the patients details and written medical prescription/request.
Give reassurance, explanations and request permission from the patient to proceed.
Children need a trusted adult with them for their comfort and support.
Assess the patient:
What is the pathology?
Why is the cast being applied?
Is there an underlying condition that may affect the way you apply the cast, e.g. diabetes,
rheumatoid, neurological impairment or allergies?
Look at the skin. Is there a wound or redness?
Which bony areas will need extra padding?
Where are the blood vessels or nerves that are close to the surface and maybe
compromised?
Is swelling expected?

Based on the answer to these questions, decide on the appropriate padding and materials
required, having them all laid out on your trolley ready.
Check the medical prescription/request again

General Preparation of the Patient

• Explain the procedure in order to gain the patients co-operation, reduce
stress and increase the patients understanding of their injury/condition

• Maintain dignity and privacy and protect clothing, appropriately screen

and cover the patient prior to the procedure

• Remove any rings or jewellery and nail polish from the effected part,
because of swelling and discolouration after injury or surgery there may
be a risk of masking signs or sudden recurrence of swelling. These
should not be replaced until the cast is removed

• Position the affected limb in the prescribed position, promoting the best
functional position for healing. This must be held and maintained until the
cast is dry, by an assistant if necessary
 Cast Complications
“PREVENTION IS BETTER THAN CURE!”

A cast being applied too tightly, this may effect:

VEINS – constriction will compress the walls of veins causing swelling, discomfort and pain.
The skin feels warm and looks blue and there is blue colour under their nails. Elevation of the
limb and exercise of the digits can be tried but the cast needs to be split or bi-valve.

ARTERIES – are usually involved due to the injury and not the cast. In arterial
compression the limb will become pale and there will be paraesthesia. The limb will be cold
and pulses may be difficult to palpate. When pressure is applied to the finger nail, the colour
does not return. Immediate medical help must be obtained. Splitting the cast or bi-valving is
urgent.

NERVE COMPRESSION – gives pins and needles sensation then limitation of movement and
pain, elevation and exercise may relieve this however if it persists after 20 mins of observed
exercise, medical advice should be sought.

INSUFFICIENT or inappropriate padding – insufficient padding may not protect the skin. Too
much padding will rub up and crease inside the cast causing uneven pressure and discomfort.

UNEXPECTED excessive swelling – will cause the same signs and symptoms as those
caused by a cast being applied to tight.

BANDAGES being applied with twisting or tension – this will cause uneven pressure and
ridges in the cast which in turn may cause plaster sores

Pressure on superficial nerves and blood vessels – As well as nerve compression,

pressure over superficial nerves may have serious consequences, for example: insufficient
padding over the head of the fibula may damage the lateral popliteal/ common peroneal nerve
causing foot drop

Plaster Sores – Occur when skin presses directly onto bone. Foreign bodies inside the cast
will cause plaster sores, with children inserting small toys or coins into the cast
 Cast Complications
Compartment Syndrome
A compartment consists of muscle, blood vessels, nerves and tendons. All these are covered
within a inelastic fascial tissue.
Compartment Syndrome is where there is raised pressure within a muscle (an Osteo-fascial)
compartment.
CAUSES:-
1.From direct arterial injury, fractures or soft tissue damage. Compartment pressure
increases due to bleeding and or oedema and swelling within the facia
2.From burns, frostbite, limb compression or constrictive cast and or dressings. Compartment
volume decreases, due to constriction, raising pressure within the compartment.
3.Combination of 1 and 2
Pressure within the compartments compromise the blood supply leading to ischemia of the
affected muscles.
SITES:
There are many muscle compartments within the body, most being in the extremities.
The most commonly effected sites are the lower limb and forearm.

SIGNS AND SYMPTOMS:

Symptoms can occur within 2 hours to 6 days following incidence. The first 12 to 24 hours
following injury is the most common. Symptoms lasting longer than 6 to 8 hours can result in
permanent damage.

PAIN:
Severe and inappropriate to the injury and not controlled by normal levels of analgesia
Increased on passive ‘stretch of he affected muscle’

PALLOR: Pale skin tone

PULSE:
May be present, gradually weakening or absent

PARATHESIA:
Pins and needles, sensation altered and blunted progressing to:-

PARALYSIS:
Loss of movement indicates permanent damage

MANAGEMENT:
Elevate the limb – with caution – only to heart height
Contact medical team
Split cast and dressings to skin
 Complication in cast
Venous Thromboembolism (VTE)
Patients having a lower limb cast applied
should be assessed for VTE risk

Deep Vein Thrombosis (DVT)

Signs and Symptoms:
Pain in calf
Oedema
Sometimes redness
Pain on palpitation
Pain in the calf on dorsiflexion of the foot

Pulmonary Embolism (PE) – blood clots in the lungs

Signs and Symptoms: Chest pain on breathing in, Heamoptysis (coughing up blood)

Complex Regional Pain Syndrome

Pain and stiffness
Hand or foot is puffy, discoloured and
moist

Problems of Union:
Mal union may cause deformity or shortening of the limb
Delayed or slow union
Non-union
 Removal or Splitting of Casts
Explain and Reassure Patient:
Show the saw on the palm of your own hand and demonstrate oscillation

Splitting of the cast to relieve pressure/swelling:

• Do one single cut along the length of the cast
• Do not just cut partway along its length or cut out a ‘V’ shape. Fluid will spread
through the area with no relief of swelling or tightness

Draw cutting lines on the cast:

• Avoid bony areas
• Avoid blood stained areas if possible
• Bivalve (follow your lines each side of the cast to leave the posterior half for use as a
resting splint)

Saw Technique:
Cut with the saw using an in and out motion holding the blade at right angles to the cast
Beware the blade gets hot enough to burn the skin:
• If you drag the blade along the cast
• through prolonged use
• If the cast is thick
• On large cast (Above knee, Hinge cast brace)
• If the blade is blunt (rotate regularly)
• Recently applied (still drying)

If the patient moves or complains:

ALWAYS BELIEVE THE PATIENT

Use spreaders to carefully separate the cast and scissors to cut the padding
SKIN CARE:
Check the limb for signs of pressure
 Indications and Treatment
Fracture Site Treatment
Humeral Shaft Collar & Cuff/ Humeral Brace

Supracondylar Above Elbow Back Slab

Olecranon Above Elbow Back Slab

Dislocated Elbow Above elbow Back Slab

Radius and Ulna Distal 3rd and up Above Elbow Back Slab/Sugar Tong

Distal Radius & Ulnar Below Elbow Back Slab Neutral

Distal Radius & Ulnar ‘Colles’ type Below Elbow Back Slab palmar
flexion/ulnar deviation
Distal Radius & Ulnar ‘Smiths’ type Volar slab wrist hyperextended

Scaphoid Scaphoid Back Slab/Below Elbow

Achilles Tendon Rupture Dorsal Slab in equinus

Calcaneus Below Knee Back slab

Medial/Lateral malleoli (mortice and Below Knee Back Slab

above)
Tri-malleolar Below Knee Back Slab

Tibia and Fibula Mid Shaft Above Knee Back Slab /

Above Knee Full Cast Split
Talus Below Knee Back Slab

Metatarsals Below Knee Back slab

Patella/Tibial Plateau/ Distal femur Above Knee Back slab

 Anatomy of the Upper Limb
It is made up of bones, muscles and
joints:
• Thumb, Fingers and Hands – Bones of the fingers, thumb and hand
Phalanges and Metacarpals
• Wrist – Carpals
• Forearm – Ulna and Radius
• Arm – Humerus
• Joints – Interphalangeal, Metacarpal
– Phalangeal, Carpo-metacarpal,
Wrist, Radio-ulnar, Elbow and
Shoulder

Bones of the Wrist

 Fractures of the hand

Fractures to the 4th & 5th metacarpals

Fractures of the 3rd & 4th metacarpal

 Fractures Casts of the Hand
of Metacarpals

Volar Slab
Application Guide
Materials Required:
1 x Length 5cm Stockinette
1 x Roll 7.5cm Sofban
1 x Roll 15cm Plaster of Paris
1 x Roll 7.5cm crepe bandage
Tape to secure 1 2 3

4 5 6 7

8 9 10 11
 Anatomy of the Wrist and Forearm
Bones of the forearm

Bones of the Wrist

 Fractures of the Wrist and Forearm
Distal Radius comminuted ‘Colles’ type

Distal Radius ‘Smiths’ type #

Distal radius ‘Greenstick’, Torus #

Scaphoid Fracture

Mid Shaft Ulna fracture

‘Night stick’

Olecranon fracture
 Casts of the Wrist
Below Elbow Back-slab Indications:
Application Guide Distal Radius fractures
Ulna styloid
Materials Required :
Distal Radius ‘Colles’ type
1 x length of 5cm stockinette Distal Radius Greenstick/Torus
1 x Roll of 7.5cm sofban Scaphoid
1 x Roll of 7.5cm Crepe bandage
1 x Roll of 15cm Plaster of Paris
• Apply the Sofban using a
50/50 overlap
• Measure the Slab from the
base of the knuckles to two
fingers from elbow crease
• Use 6 to 8 layers
• Cut a half circle for the thumb
area
• Secure slab using wet crepe
bandage under slight tension 1 2

3 4 5

6 7 8
 Casts of the Wrist and Forearm
Above Elbow Back Slab Indications:
Application Guide Distal Humeral fractures
Materials Required: Supracondylar
Olecranon
1 x Length of 7.5cm Stockinette Dislocated Elbow
2 x Rolls 7.5cm Sofban Radius and Ulna distal 3rd up
2 x Rolls 7.5cm crepe bandage Ulna Nightstick Fractures
1 x Roll 15cm plaster of Paris POP Radial Head
1 x Roll 7.5cm plaster of Paris POP
More of the 15cm might be required
for larger arms

• Unless otherwise stated make sure the elbow • Be aware of bony prominences
is held at 90° degree angle • Medial and Lateral supporting slabs
• Sofban should be applied with a 50/50 need to be 6 to 8 layers thick
overlap • Back Slab needs to 6 to 8 Layers thick

1 2 3 4

5 6 7 8
 Casts of the Wrist and Forearm
Above Elbow Back Slab
Application Guide
• Submerge slab into tepid water and squeeze • Mould back slab into position finishing three
excess water away fingers away from the arm pit and to the base
of the 5th Metacarpal
• Mould into position your two supporting slabs • Apply your wet crepe bandage using 50/50
medially and laterally overlap using light tension and secure with
tape

9 10 11 12

13 14 15
 Anatomy of the Lower Limb
Bones of the lower Limb, Feet and Toes
The lower limb is constructed to carry the body weight and to move the body from place to place
The lower limb comprises the thigh, lower leg, ankle, feet and toes
 Fractures of the lower limb

Spiral Tibia fracture including

Fibula

Comminuted Tibia plateau

fracture including fibula
head Avulsion fracture base of 5th

Calcaneus fracture

Medial Malleolus and distal fibula

 Below Knee Back slab
Below Knee Back Slab Application Guide
Materials Required:
Indications:
1 x Length of 7.5cm stockinette Ankle fractures, navicular,
2 x Rolls 15cm sofban talus, malleoli
2 x Rolls 15cm Plaster of Paris P.O.P Metatarsal fractures
2 x Rolls 10cm Plaster of Paris P.O.P Calcaneus fractures
2 x Rolls 15cm crepe bandage Soft Tissue injuries
POP width dependent on leg size

1 2 3 4

5 6 7 8
 Below Knee Back slab

9 10 11 12

Gap for swelling

13 14 15 16

• Apply the stirrup moulding and smoothing • Apply the back slab leaving the knee crease
into the leg free moulding and smoothing the two slab
together
• Make sure the ankle/foot is still at 90 degrees • Turn back your stockinette

• Apply your crepe bandage using a 50/50 overlap. Secure in place

with tape or additional POP. Make sure you have not joined edges
together preventing swelling.
 Below Knee (Equinus) Anterior slab
Achilles Tendon Dorsal Below Knee
Slab
Materials Required:
1 x length 7.5cm stockinette
1 x Roll 15cm Sofban
2 x Rolls 15cm Plaster of Paris or 1 x 20cm
2 x Rolls 15cm crepe bandage or 1 x 20cm

1 2 3

4 5 6
 Casting Standards
British Orthopaedic Association

Casting, the application, adaption and removal of patients casts, is a SKILL requiring
knowledge and judgement, not forgetting sensitivity, in order to safely care for the
patient.
Casting is not solely carried out by orthopaedic practitioners, but nurses and other
members of the multi-professional team.
Whilst most casting takes place in the Plaster Room many patients are cared for with
Emergency Department, Minor Injury Units and other clinical areas. It is hope that
practitioners working within these areas will be able to use the guidelines to help develop
local standards which specify the resources they require, the methods that they will use
and the outcomes that they should expect.
The care described in the standards is based on the patient’s rights to be valued as a
unique person and to retain control of their own self (DOH 2010, Mental Capacity Act
2005, NHS Wales 2010)
A patients needs can include deficits in their knowledge about why they need a cast and
care of themselves in a cast, biological crises, difficulties in the environment or
restrictions imposed by treatment regimens, such as the inability to mobilise themselves
in the usual way.
The standards within this document are not new. Instead they represent practice that the
British Orthopaedic Association Casting Committee (BOACC) believes should be integral
part of care. The standards have an audit protocol, which identifies a method by which
actual care can be compared with the recommended standards.