Care of Limb in Plaster

In my experience, I have noted that many orthopedic problems can be nipped off in the bud if there is awareness of some of the early warnings signs among the people and they take medical help and advice in time.

Fractures and injuries are a commonplace occurrence these days. Plaster application is an essential part of the treatment in most of these cases – whether an operative or non-operative procedure is done for the management.

Plaster casts are applied as a treatment for a fractured bone, a sprained joint, ligament injuries, as a postoperative treatment etc. to give rest and immobility to the affected limb till the injured/operated tissue heals keeping the limb in the most optimal position. Care of the plastered limb is very important for a good outcome of the procedure done.

Plaster casts are made up of either Plaster of Paris or Fiber-glass or other Synthetic material. The latter two are light but costly as compared to the former. They facilitate the healing of fractured bones by holding them in place and avoiding their displacement.

You need to take good care of the cast applied by the doctor, so that it can protect your fractured bones until it heals over a period of time.

A small amount of swelling occurs after any injury and it is normal. Fractures and other severe injuries can lead to more swelling. Swelling is usually greatest during the first 72 hours of injury.

After plaster application keep your arm or leg elevated on soft and thick pillows until the cast is completely dry. It is best elevated to above the level of your heart. This will help to reduce swelling.

After the plaster is dry continue to keep your arm or leg raised on a pillow for 12 – 24 hours (depending upon the initial swelling) and take rest. This will help swelling to go down. Continue to do this for another 12 hours if the cast still feels tight. In case of the lower limbs the pillow is placed such that the heel is out of the pillow and hanging free when you are lying on your back on the bed, otherwise you may develop painful heel later on.

In case of upper limb, use broad arm sling support, so that the arm does not hang down. Hanging down will increase the swelling.

The two most delicate structures prone to be compressed and damaged by the pressure due to the swelling in a plastered limb are-NERVES and BLOOD VESSELS.

Always keep moving your fingers/toes to their full range of movement frequently. You should be able to fully extend your fingers or toes. This will move the muscles under the cast and will maintain the circulation of the limb, which in turn will help in reducing the edema and swelling of the limb further and avoid any pressure. Make sure you have sensations in the fingers or toes of the casted limb by touch. If the movements of the fingers/toes are OK and the sensations are good, your nerves are not compromised.

A simple test to have a basic and rough idea about the distal circulation of your plastered limb– Squeeze a nail of the casted limb until it is white and then release the pressure. The circulation is fine if the pink color returns quickly in two seconds. Do it three times a day to be sure that the circulation (Blood Vessels) in the plastered limb is good.

Two plastic bags covering the cast one over the other will protect the cast on a wet day or when bathing. Tape both bags securely, the second bag a little higher than the first. Try using sticky plaster to seal the bag at the top and bottom to make it water tight so that water can’t trickle inside and damage your skin. Remove as soon as possible to prevent damage from perspiration.

Don’t get your plaster cast wet. Do not shower. Water will not only weaken it, it may also soak the cotton and other soft material inside the cast (even in case of a water resistant fiber glass or synthetic cast) and will ultimately result in formation of skin ulcers which may not be visible or even evident from outside. There will also be no evidence of the damaged skin once the soakage dries up. You cannot detect the skin damage/ulcer as it is hidden under the cast until it gets infected and starts smelling foul. Keep your plaster dry at all cost.

The skin underneath the cast is more sensitive and delicate due to the perspiration which collects inside. Do not put anything like powder, spray, or a foreign object inside the cast to relieve any itching. They could cause an irritation or infection. Even if the plaster cast makes your skin feel very itchy, don’t be tempted to poke anything underneath it. You need to take special care in case of children regarding this. This could lead to a nasty sore. The itchiness generally settles down after a few days by itself. This is caused by the irritation of the collected dead skin and perspiration over a period of time under the cast and it gets better by itself again over a period of time when the underlying new skin adjusts to the presence of this collected dead skin.

Never try to trim or alter the position of your cast. Never use a box cutter, power saw, or razor – you might cut yourself! Do not try to mend or repair the cast by yourself.

Avoid resting your cast on any hard surface such as the back of a chair or on the table. It will not only damage the cast, it may displace the fracture as well, besides causing pressure sores inside.

Do not put weight or walk on your cast if your doctor has not given the permission to do so.

Lifting anything heavy or driving will either spoil the cast or strain and damage the underlying healing structures.

Use crutches or a sling for the period required, as advised by your doctor.

Any art with markers is fine – a well decorated cast can make a nice memento to keep after it is removed, but don’t use ball points or pencils as they may dig out channels in the cast weakening it.

You should contact and visit the ER of the Hospital immediately if:

• Pain is not relieved by raising the limb and taking pain killers.
• Skin color changes such as a blue, pale or grey of fingers / toes.
• Pins and needles or loss of sensation occurs in fingers / toes.
• Inability to move fingers/toes below the cast.
• A bad odor or staining coming through the cast.
• A too tight cast. If you feel that your plaster cast is too tight even after keeping it elevated for 24 hours.
• A foreign object inside the cast.
• Your fingers/toes of the fractured limb will normally feel stiff after a period of inactivity but if they don’t get better even after moving them for 10-15 minutes or so.
• You feel that your cast is too loose-it may happen if the initial swelling was much at the time of cast application.
• The cast is broken or cracked, soaked or has become soft at some place.
• The skin underneath or around the edge of your cast feels sore.

If you take good care of your cast, your cast will take good care of you. A plaster cast is a rigid support covering that keeps the broken ends of your bone touching each other and aligned so the bone heals in the correct manner. Without a cast, your broken bones may heal crooked or not at all.

Remember, the cast is only an outside hard and non-expandable cover to hold the fractured limb in the proper position. It is applied to the limb keeping in mind the space required by the limb and the swelling present at the time of application. If it is applied loose at the time of application to accommodate the swelling, it cannot hold the fracture when the swelling goes down. This is the reason why your doctor calls you after sometime to have a change of the cast as it becomes loose after the swelling subsides. He may also decide to apply an incomplete cast (called SLAB-i.e. covering only a part of the circumference of the limb) in the beginning and change it into a complete cast later when the swelling goes down.

After application, the cast cannot accommodate any further space inside as it is not an elastic structure. Hence, any newly developing swelling cannot be accommodated inside and any such swelling will only cause pressure on the delicate and sensitive structures of the limb inside the cast. Nerves and Blood Vessels are the structures inside which are most delicate and prone to suffer an irreversible damage due to this pressure.

The pressure on Nerves gives you the symptoms of- Tingling/numbness in fingers/toes and inability to move them.

The pressure on the Blood Vessels gives you the symptoms of — change in the color of the fingers/toes to bluish/whitish/pale (depending upon the race).

Do not take these symptoms lightly or overlook them-let your doctor decide how much attention they need.

This pressure on the Nerves or Blood Vessels, if not detected, reported and relieved in time- may lead to a permanent damage to the limb.

The idea behind writing this article is to educate the patient so that he can understand and protect his plastered limb. He can thus avoid many complications which could arise due to ignorance and hence get the full benefit of the surgery and plaster application.