ABOVE ELBOW SLAB

Indications

• Radial shaft fractures
• Ulnar shaft fractures
• Elbow fractures
• Distal humeral fractures

Alternatives – Open reduction with internal fixation

Above elbow cast (Image courtesy NHS Foundation Trust)

  Consent

• Verbal – If has capacity and sedation is not used
• Written – If has capacity and sedation is used
• Not required – if lacks capacity. For emergency procedures, brief verbal discussion is recommended if the patient is alert.

Potential complications:

• Failure of reduction or immobilisation
• Thermal burns – heat released from setting plaster
• Neurovascular compromise
• Pruritis
• Dermatitis
• Abrasions and pressures sores/ with risk of infection/
• Joint stiffness

  Infection control:

• Standard precautions
• PPE: non-sterile gloves, apron

Area:

• Plaster room or bed space

Staff:

• Procedural clinician
• Assistant
• Additional clinician and nurse if procedural sedation is required

Equipment:

• 5cm cotton padding/ slightly narrower than arm/
• 15 cm plaster for the back slab
• 10 cm plaster for stirrup
• Trauma scissors
• Bowel of cold water
• Crepe bandages
• Tape

Positioning:

• Sitting with the elbow supported on a table or by an assistant
• Proceduralist applies plaster
• Thumb pointing to own shoulder
• Shoulder abducted slightly
• The elbow flexed to 90 degrees
• Forearm in neutral pronation and supination
• Wrist in neutral or slight extension

Medications:

• Titrated IV pain relief before procedure – Fentanyl 25-100 micrograms or Morphine 2.5-10 mg
• Followed by procedural sedation if it is required
• Aim for minimal dose required

Cast preparation:

• Estimate plaster length by lying a dry splint next to the uninjured arm.
• Layers: 8-10 layers along the under surface of the arm, 10-12 layers for stirrup from axilla to axilla
• Distal margin; distal palmar crease – in forearm fractures and proximal to radio-carpal joint in distal humeral fracture
• Proximal margin – 5 cm below the axilla

Cast application:

• Ensure adequate analgesia before the procedure
• Inspect the extremity before splinting
• Apply stockinette to arm beyond margins of plaster – allowing fold to a smooth edge
• Cut a small hole in the stockinette for the thumb
• Apply 2-3 layers of cotton padding beyond the plaster margins
• Tear or cut cotton padding as it passes through the first webspace.
• Ensure the elbow is well padded and padding overlaps itself by 25-50% with minimal creases
• Submerge the prepared dry back slab in water until bubbling stops, then remove
• Squeeze out excess water, smooth on a flat surface and apply along the ulnar border of the forearm
• Submerge the prepared dry stirrup splint in water until bubbling stops, then remove, squeeze, smooth apply along the lateral aspect of the forearm extending around the elbow to the medial axilla.
• Turn back padding around distal and proximal margins of plaster
• Apply crepe bandage firmly over the slab and fasten it with tape

Gently mould plaster to patient anatomy/palm, particularly/ maintaining wrist and elbow position until hardened

BELOW KNEE BACK SLAB

Indications:

• Fractures of distal tibia and/or fibula
• Tarsal fractures
• Metatarsal – non-weight-bearing management

Below Knee cast (Image courtesy NHS Foundation Trust)

Consent:

• Verbal – if had capacity and sedation is not required
• Written – if capacity and sedation are required
• Not required – if there is a lack of capacity, a brief verbal discussion of the procedure is recommended if the patient is alert.

Potential complications:

• Failure – of reduction or immobilisation
• Thermal burns – heat released during plaster setting
• Neurovascular compromise
• Pruritis
• Dermatitis
• Abrasions and pressure sores
• Joint stiffness
• DVT

Infection control

Standard precautions

PPE – non-sterile gloves, apron

Area:

• Plaster room or bed space, resus bay if procedural sedation is required

Staff:

• Procedural clinician
• Assistant
• Additional clinician and nurse if procedural sedation is required

Equipment:

• Stockinette – optional
• 5 cm and 10 cm cotton padding / for foot and leg/
• 15cm plaster for back slab – slightly wider than leg/
• 10 cm plaster for stirrup – approximately leg diameter
• Trauma scissors
• Bowl of cold water
• Crepe bandages
• Tape

Positioning:

• Supine or prone
• Assistant supporting weight of leg in position
• Proceduralist applies plaster
• Ankle: flexion to 90 degrees – neutral position
• Subtalar joint and hindfoot: neutral inversion/eversion
• If supine – a towel under the knee can assist position

Medications:

• Oral pain relief – 60 min before the procedure – Paracetamol, Ibuprofen, Oxycodone
• Titrated iv pain relief – Fentanyl 25-100 micrograms, Morphine – 2.5-10 mg iv
• Consider procedural sedation

Cast preparation:

• Estimate plaster length by laying a dry splint next to the area to be splinted – use an uninjured leg
• Layers: 12 layer back slab along posterior leg, eight layers from stirrup from above midcalf to above midcalf
• Distal margin: distal to metatarsal heads on plantar surface – continue beyond toes for phalangeal fractures
• Proximal margin: 2 cm below the head of the fibula

Cast application:

• Ensure adequate analgesia before the procedure
• Inspect the extremity before splinting
• Apply stockinette to leg beyond margins of plaster – allowing fold to a smooth edge
• Apply 2-3 layers of cotton padding beyond plaster margins proximally and then distally
• Ensure heel and malleoli are well padded with padding overlapping itself by 25-50% with minimal creases
• Submerge the prepared dry back slab in water until bubbling stops, then remove
• Squeeze out the excess water and smooth it on a flat surface
• Apply on the posterior leg, starting from the base of the toes and extending up to the leg
• Submerge the prepared dry stirrup splint in water until bubbling stops, then remove, squeeze, smooth, and apply halfway up the calf, under the ankle, and above the midcalf.
• Turn back padding around distal and proximal margins of plaster
• Apply crepe bandage firmly over the slab and fasten it with tape
• Gently mould plaster to patient anatomy, maintaining the position until hardened

Post-procedure care for all plasters:

• Check x-ray, circulation and function
• Confirm fracture reduction with pos-procedural xray
• Check capillary refill and comfort
• Check plaster position
• Provide with plaster care instructions
• Elevate limb when possible – decrease pain and swelling
• Do not wet the plaster
• Use a plastic bag to protect plaster while in the shower
• Return if damaged, painful, numbness, or skin changes

HANGING U SLAB APPLICATION

(Video courtesy Orthopedic Teaching)