Complications

of
Plaster Cast
POP Course
By
ORTHOPAEDIC DEPARTMENT, SGH
24 – 25 Jul 2008
 Scope :

• 1. List of Complications
• 2. Causes / Factors leading
to complications
• 3. Precaution / How to
prevent complications
 Complications of plaster cast
1. Neurovascular compromise / impairment
2. Skin complication
3. Volkmann’s Ischemic Contracture
4. Joint Stiffness
5. Cast - Induced Infection
6. Cast syndrome
7. Delayed in diagnosis of Thromboembolism
and arterial injury
8. Other complications
 Neurovascular impairment
Causes
1. Tight cast  Neurapraxia
- Common Peroneal nerve
- Median nerve (carpal tunnel)
- Ant interosseus n (cubital fossa)
- Ulnar nerve (cubital fossa)
2. Inappropriate strapping or
positioning of material localised
pressure  occlusion of a vascular
anastomosis.
Prevention
- Appropriate padding ,
positioning and tightness
of cast
- Avoid leg externally
rotated for prolonged
period to prevent Common
Peroneal n. injury
 Skin complication

1. Pressure sores

2. Cast Dermatitis
3. Plaster Burn
 Causes of Skin complication
Pressure 1. Uneven bandaging technique
2. Insufficient padding especially over bony
Sores
prominences
3. Cast too tight or too loose
4. FB inside the cast
S & S:
- Pain + local heat, Rise in temperature, Recurrence
fingers/toes swelling, Offensive smell, Discharge,
Staining of cast

Cast 1. Poor ventilation and hygience

2. Allergic reaction to cast chemical
Dermatitis
S & S:
- Wetness under cast, Discharge, Excessive irritation
Plaster Burn 1. Hot dipping water
2. Thick cast  too much heat
3. Inadequate ventilation
4. Fast setting cast
5. High room temperature
6. Use of highly insulating pillow
Pressure Sores
Cast Dermatitis
 Volkmann’s Ischaemic
Contracture

Increases intra- Venous + lymphatic

compartmental pressure obstruction + severe
vasospasm of arteries

POP
Severe ischemia of
#  edema & extravasation of the nerves and the
blood into a confined space muscles

Compartment
Syndrome
Joint stiffness / muscle atrophy
 Cause : Prolonged static splinting or cast
 Soft tissue & joint contracture develop (esp
finger jt)
 Cast- Induced Infection

• Rare
• Infection including Fungal, parasitic and bacterial
infections
• Prevention
– plaster buckets be cleaned or replaced after use
and not allowed to stand full of stagnant water as
a potential culture medium
– Patient should be advise that POP should not get
wet or dipped in water
 Cast syndrome / SMA syndrome
– Caused by an obstruction of the 3rd portion of the
duodenum resulting from constriction by the superior
mesenteric vessels when body immobilized in
hyperextension position

– Causes :
– Prolonged supine positioning
– Spinal instrumentation
– Spinal orthosis or body cast

– S&S: nausea, vomiting, abdominal pressure and

vague abdominal pain/ epigastric pain & S/Sx of
electrolyte imbalance.
Obstruction of
3rd part of
duodenum fr
constricting
SMA when
body
immobilized in
Aorta
hyperextension

SMA
Duodenum
 Cast syndrome / SMA syndrome

• Prevention
- Patient education to recognize cast syndrome,
which can develop as late as several weeks or
months after cast application

• Treatment
– Cutting a generous hole over the epigastrium or
complete removal of the body cast
– Insertion of a nasogastric tube to decompress the
stomach
– Electrolyte replacement therapy.
 Delayed diagnosis of :
 1. Thromboembolic complications
 2. Arterial Injury

 Presence of a cast over a #  masking the

diagnosis of DVT and arterial injury
 Cardinal signs of arterial insufficiency are
obscured
 Venography needed for DVT diagnosis
 Other Complications
1. Cast induced open #
 - Occur in a #ed extremity where the bone is
very close to the skin such as pretibial region
(Abrasion)

2. Disuse Osteoporosis
- Cast immobilization is a reversible biological
- Reversible

3. Avascular Necrosis of the Femoral

Head
- Known to be caused by hip spica cast used to
treat congenital dislocation of the hip in infants.
 Other Complications
4. Malunion/Malalignment
- Loose POP

5. Cast- Associated Hypertension

- It is thought to be caused by stretching the
sympathetic network around the blood vessels.

6. Obstruction of a Ventriculoperitoneal (VP)

Shunt by a spica cast
- Has been reported by Gerber ( 1977 )

7. Cast- Induced Esophagitis

- Cause by a body cast, has been described by
Gryboski et al. ( 1978 )
 Other Complications
• 8. Cast- Induced Hypercalcemia
– Also known as immobilization hypercalcemia,
– Associated with polyostotic diseases such as
• Multiple Myeloma,
• Metastases,
• Paget’s disease of bone,
• Malignant Lymphomas, and
• Leukemias.

• 9. Thrombophlebitis of leg vein

- Distal 1/3 tibia immobilization  Foot in Equinus
- Extreme equinus position  muscles become so relaxed
 loss of the "pumping" action unable to generate
enough tension to the calf veins  thrombophlebitis
 Precautions to prevent
complications
• Knowledge of patient
i.e.: Medical History, allergic hx, etc
• Proper positioning of the part
• Sufficient padding, extra for bony prominences
• Apply cast evenly and smoothly conforming to
anatomical contours
• Apply to required length i.e.: immobilize joint above
& below.
• Apply to required thickness
• No localised pressure ( indentations ) by fingers or
thumb before cast sets
 Precautions to prevent
complications
• Do not move at joints while cast is being applied
• Avoidance of varying tension in a roll of padding
or plaster as it is being applied
• Apply slab for swollen limb – not a circular cast
• Paralysed limbs – contraindication
• Neuro-vascular assessment
• If Allergic reaction  remove cast, cleanse skin,
reapply using other material
• If in doubt of any complication  Split or open
cast to inspect
• Patient Education on care of POP, possible
complication and early S&S of complication
• THANK YOU