01.07 Casting & Splinting

Today we will be learning about casting and splinting. By the end of this lesson you'll be able to differentiate between the types of casts and splints, understand the nurse's role in casting and splinting, and will understand the nursing considerations when caring for these patients.
So casting and splinting is necessary to achieve proper bone alignment and maintain tissue perfusion while protecting the affected extremity during healing stages. A cast is a rigid device that immobilizes and allows for early mobility and reduces pain. Splints are usually two pieces of rigid plastic that are secured on either side of the injured area. Splinting is different from casting because it is more temporary immobilization versus casting which is a little bit longer term. Splinting also supports the affected body part and usually can be removed.

Let’s dive in a little bit deeper into casting and what types of casts you may see. So just to review, casts immobilize and maintain alignment. This is really important for healing and perfusion. One cast that isn’t really commonly used is a plaster cast such as plaster of paris. These casts are really a pain because they take a really long time to dry and you have to be super careful when you’re handling them to prevent them from getting indentations. So two things to remember if you see these casts- 1- handle with your palms of hands only while it is still drying to prevent indentations and 2- turn the extremity every 1-2 hours unless contraindicated to help it dry faster. Synthetic casts like fiberglass or polyester-cotton knit are seen a lot more frequently because they are so much nicer and more convenient - for both the patient and for us who are handling the cast. They are still super effective but the drying time is a whopping 30 minutes vs 24-72 hours that you would see with a plaster cast. So when I was 10 years old, my brother jumped on my arm playing leap frog and broke my arm. I was stuck with a cast just like this guy in the picture - but it was okay because I was so excited to have my friends and teachers sign my cast.

Now that we understand casting a little bit more, let’s take a closer look at splints. So splints can be used for fractures and non fractures like a sprain or strain. They can be used pre-hospital until further medical treatment is available such as out in the field with a sports injury- using two rolled up towels and tape until the patient can be transported. In the hospital you'll see a splint that's similar to this picture for an ankle injury. You can see the hard pieces of plastic on both sides of the leg secured by tape. Splints are also commonly seen in the upper extremity because they are more non weight-bearing so a less sturdy support is usually sufficient. Splints are also used in lower extremities and can be held in place by an ACE wrap.

Let’s look at application and where your role as a nurse comes in. So ER nurses typically apply casts/splints. They also will monitor circulation, perfusion, sensation, pain, etc as well as monitor for any complications. When patients are sent to the floor, floor nurses monitor for the same things and manage any complications that may arise. We will touch on complications to watch for in a little bit. Floor nurses also apply slings and walking boots according to doctor’s orders. Slings can help support the upper extremity with the added weight that a cast adds. So let’s look at how much of a difference a sling can have for a patient. So I’ll draw a picture of a person with an upper extremity cast. Here’s the arm and the cast. So with the weight of the cast the arm is not going to be supported. I’ve had patients that have shoulder pain even just due to the weight of lugging a big cast around. So let’s draw another picture but this time the patient has a sling on. Okay so can you see that the arm is now supported. This kind of takes the pressure off of the shoulder and is a lot more comfortable for the patient. Walking boots can also be added to the outside of a hard cast and help the patient ambulate.

So why do we cast and splint? We do this to help immobilize and protect the extremity while it is still healing. It also helps achieve correct alignment which helps maintain perfusion and circulation which leads to correct healing. Without casting or splinting, bones could heal incorrectly which could cause increased pain, musculoskeletal problems, and predispose for fractures in the future which are all no good things that we want to avoid!
The nursing priorities when caring for these patients are all centered around frequent monitoring and neurovascular checks.
With your assessment you’ll be looking at the patient’s perfusion and circulation. It’s also important to use elevation of the extremity to help prevent edema. This is as simple as putting the patients affected extremity on pillows. Patient’s that I’ve cared for even say that the elevation helps a lot and even helps with pain control. Another important thing to monitor is the patient’s sensation and noting any changes like new numbness or tingling or decreased sensation. These patients will be in a lot of pain so pain control will be a big priority. Make sure to watch for signs of infection like as new fever, hot spots on the cast- when you are actually feeling the cast, foul odor coming from the cast, and increased pain. Your neurovascular checks will depend on the type of floor you’re working on, the patient’s acuity, and current condition. For example, my floor is typically neurovascular checks every 4 hours for one of these patients, but if my patient is having acute changes like changes in sensation I’ll be monitoring them a lot more frequently than that.

Check your orders!! Doctors will specify weight-bearing status like non weight-bearing or weight bearing as tolerated. You could also see orders for a sling/walking boot or for ice. If you don’t have activity orders for your patient make sure you clarify with the doctor BEFORE getting the patient out of bed. Icing orders could look something like ice for 20 minutes on and 20 minutes off or just PRN comfort. If you're applying the cast/splint, make sure it’s not too tight and the limb is in proper alignment to maintain perfusion. The patient should be able to move their fingers/toes and have feeling distal to the injury.

Some of the important complications to watch for are compartment syndrome, pressure sores, infection and thermal injuries. Compartment syndrome happens when the pressure builds inside the cast and has nowhere to go. So let’s pretend this circle is the patient’s arm and this outer circle is the hard cast. The swelling will cause the arm to move outward towards the cast and has nowhere to go. What’s the problem here? Well with a hard cast it doesn’t give - that’s kind of it’s job right? But this is a problem because all of that built up pressure compresses blood vessels which is NO GOOD. This is a medical emergency and the doctor needs to know ASAP if you suspect this as it can lead to limb loss. This can present as increased pain, loss of distal pulses, and discoloration. Pressure sores can occur if there is some part of the cast/splint pressing against the skin wrong or if something gets stuck under the cast. Infection can happen if something is stuck under the cast and causes a scratch that can get infected. Thermal injuries can happen with the plaster of paris casts. When these casts are applied the patient can feel a very warm sensation on their skin, so just monitor to make sure the skin doesn’t get too hot.

There are a couple main things we want to be teaching our patients. We want to educate patients to report any changes in sensation such as numbness/tingling, a cold sensation, or increased pain. Make sure to do some education about cast care. 1- casts can get super itchy but patient’s should NOT put anything down the cast to scratch. When I had my cast I’ll admit that I totally put one of those flexible rulers down mine to itch. 2- The cast should be clean and dry at all times. Patient’s may look at you like uh yeah okay so you don’t want me to shower for 6 weeks or until my cast comes off? Well no they can still shower just make sure they cover the cast with a trash bag and tape it good or just stick the extremity outside the shower to prevent it from getting wet. 3- Maintain cast/splint integrity. Patients should not do anything to alter the cast in any way. I was working in the ER once and a lady came in who sawed off her own cast with a steak knife because it was too tight. With proper education maybe this could have been prevented - did she know that she shouldn’t cut off her cast? Did she know that elevation can help with edema? Did she know she could contact her doctor prior to cutting off the cast? Patient education is super important because that whole scenario could have been prevented with good education. Make sure to teach some about signs of infection and what to look for. We should also be educating about doctor’s orders such as weight-bearing status, temperature therapy, and elevation - to hopefully prevent your patient from sawing off their cast!

Some of the nursing concepts for a patient with a cast or splint include comfort, functional ability, and tissue and skin integrity. Patients could have an alteration in comfort due to the pain or just the discomfort of having the cast/splint. Their functional ability is altered because they cannot use their extremity the same for a while so lets say a female patient is right handed and breaks her right arm.. that’s going to complicate things when she needs to do her hair, shower, go to the bathroom, etc. Tissue and skin integrity is also a priority nursing concept. As we addressed before tissue perfusion is huge with casting/splinting and patient’s can also have an alteration in skin integrity if they develop a superficial infection under their cast.

The key points I want you to remember when thinking about casting/splinting include frequent neuro checks to assess perfusion, circulation, and sensation. We should be monitoring and managing complications such as compartment syndrome, pressure sores, infection, and thermal injuries. Pain control is a priority- this can be treated with medication, icing, elevation. We should follow and educate about doctor's orders such as weight-bearing status, cast application, slings/boots as indicated, and ice. We also should maintain cast integrity and teach about cast care such as preventing itching/sticking anything under the cast, keeping the cast clean/dry, and maintaining cast/splint integrity.

Okay guys, that’s all on our lesson about casting and splinting. Make sure you check out all the resources attached to this lesson. Now, go out and be your best self today. And, as always, Happy Nursing!