Casting: Pearls and pitfalls learned while caring for children's fractures

Casting is a routine procedure used for fracture care in the pediatric population. The purpose of this review is to provide pearls and pitfalls that our institution has learned from previous literature. When applying the cast, we recommend using cotton padding for the liner and fiberglass or plaster depending on how much swelling is expected. A well-molded cast must be applied in order to prevent further fracture displacement.Cast valving is a valuable technique that allows a decrease in pressure which prevents discomfort and complications like compartment syndrome. Preventing thermal injuries, skin complications, and a wet cast are other important considerations when caring for casts.Appropriate use of a cast saw, avoiding pressure spots,and properly covering the cast are ways to respectively prevent those complications. Lastly, patient education remains one of the most valuable tools in ensuring proper cast maintenance.     

Casting: Pearls and pitfalls learned while caring for children’s fractures

Casting is a routine procedure used for fracture care in the pediatric population. The purpose of this review is to provide pearls and pitfalls that our institution has learned from previous literature. When applying the cast, we recommend using cotton padding for the liner and fiberglass or plaster depending on how much swelling is expected. A well-molded cast must be applied in order to prevent further fracture displacement. Cast valving is a valuable technique that allows a decrease in pressure which prevents discomfort and complications like compartment syndrome. Preventing thermal injuries, skin complications, and a wet cast are other important considerations when caring for casts. Appropriate use of a cast saw, avoiding pressure spots, and properly covering the cast are ways to respectively prevent those complications. Lastly, patient education remains one of the most valuable tools in ensuring proper cast maintenance.     

A human skull cast model for training of intracranial microneurosurgical skills

Skillful microsurgical techniques such as microvascular anastomosis and repair of nerves require dedicated and extensive laboratory training. Human microneurosurgery poses several additional technical difficulties, as the intracranial procedures are often performed through a narrow operative space at a considerable length, using knee-bend instruments. This article presents a laboratory model to simulate microneurosurgical procedures in humans. A human skull cast model made from plaster is cut such that, when placed on a operating table, it represents a standard position of a pterional approach and that the point of operation is at the same depth as the hypothetical circle of Willis. A standard pterional opening is made in de skull cast and the model is placed over the rat. Subsequently, all surgical procedures starting from tissue preparation to performing an arterial, venous, and/or nerve repair are performed with the cast over the rat using microneurosurgical knee-bent instruments and a surgical microscope. Microsurgical procedures such as end-to-end vessel anastomosis and nerve repair are technically much more challenging and difficult to execute when performed through the pterional opening of the human skull cast than without the cast model. Moreover, the cast model useful in training microsurgical techniques performed with long knee-bend instruments. It is concluded that the skull cast model represents a useful method to train intracranial microneurosurgical blood vessel anastomosis and nerve repair.     

A simplified method of total contact casting for diabetic foot ulcers

A simplified method of total contact casting for diabetic plantar ulcerations is described in which a standard, well-molded short-leg walking cast is applied. Weekly cast changes are performed initially, followed by longer cast change intervals. Either fiberglass or plaster casting tape appears equally efficacious. Healing of all ulcers was demonstrated in 12 patients treated with this technique.     

Keeping casts dry: A comparison of commercially available cast protectors using a mechanized short arm cast model

BackgroundUpper extremity fractures requiring cast immobilization are exceedingly common, especially in the pediatric population. Studies have shown improved outcomes when patients can participate in water-based activities while casted. However, waterproof cast material is not feasible in all clinical settings and wet cast complications remain a source of morbidity and expense. External cast protectors play an important role in preventing wet casts, but the efficacy of various commercially available brands during relevant water-based activity remains unknown.PurposesTo determine if there are differences in the rate and extent of moisture exposure for four commercially available cast protectors using a mechanized cast arm model and human volunteers.MethodsA mechanized arm model was developed with four implanted humidity sensors. Cast protectors were applied over the arm, the model was submerged in water, and moved back and forth, simulating cast-wearers’ motion. Data regarding humidity was recorded for successive 10-minute trials. Trials were analyzed using a mixed effects linear model to determine change in humidity over time. The top and bottom performing cast protectors were then applied to four adult volunteers prior to thirty minutes of swimming. Questionnaires regarding comfort and a qualitative assessment of cast wetness using a chemical color indicator were completed.Results372 instances of sensor data from 96 10-minute trials was collected. The CVS, SealTight and Walgreens brands showed significant increases in humidity beginning at 10, 20 and 20 minutes, respectively. DryPro showed no significant increase in moisture level up to 50 minutes. In successive trials up to 120 minutes, DryPro showed only a 2% increase in moisture. In human subjects testing, 3/4 casts underneath CVS protectors had some degree of wetness-related color change that would require cast change as compared to 0/4 casts underneath DryPro protectors.ConclusionsSignificant differences exist between commercially available cast protectors. Vacuum-sealed protectors performed best in both mechanical and human subject portions of this study and allowed minimal change in humidity for extended periods of sequential water immersion. Their cost is notably less than management of a wet cast. Lower-performing products may expose cast-wearers to an increased risk of wet cast complications.     

The efficacy of two methods of ankle immobilization in reducing gastrocnemius, soleus, and peroneal muscle activity during stance phase of gait

BACKGROUND: Immobilization to limit muscle activity is a common therapeutic and posttreatment event. There are potential time and resource savings if a prefabricated boot can replace a custom applied cast. The purpose of this study was to determine if muscle activity reduction is similar using a fiberglass cast versus a prefabricated (Aircast FoamWalker) boot. METHODS: Surface EMG data were recorded from the gastrocnemius, soleus, and peroneals of 12 normal adults while walking barefoot, in a fiberglass cast with a cast shoe (cast), and while wearing an Aircast FoamWalker (boot). Subjects walked at their self-selected speed for 10 trials in each condition, and the order of barefoot, cast, and boot was randomly assigned. The data were rectified, integrated across stance phase and normalized to a percent of each subject's barefoot mean integrated EMG (iEMG) value. For each muscle, a linear mixed-effects statistical model (subject by trial by condition) was utilized to determine if iEMG activity levels were reduced by immobilization compared to barefoot walking. RESULTS: Activity for all muscles was significantly lower in the boot compared with barefoot (p <.05). The cast iEMG levels were significantly different from barefoot for the soleus and peroneals (p <.05). Gastrocnemius activity was significantly decreased in the boot when compared with the cast (p <.0001). The greater reduction in iEMG levels for the boot indicates that it is superior to a fiberglass cast in reducing gastrocnemius muscle activity during the stance phase of gait. CONCLUSIONS: The data show that a prefabricated boot is as effective as a custom applied cast in reducing soleus and peroneal muscle iEMG during stance phase. The boot was more effective in reducing gastrocnemius activity when compared to the cast. CLINICAL RELEVANCE: This study suggests that a prefabricated boot may be used in place of a custom cast when the goal of treatment is to limit muscle activity of the leg.     

Experiences in the after treatment of surgically treated ligament rupture of the ankle joint using a special shoe

Early surgical reconstruction of lesions of ankle joint ligaments is generally accepted and yields best functional results. The wearing of a cast for 6-7 weeks limits movement to a greater extent than required for ligament healing. Functional physiotherapy and the use of a special shoe results in healing equal to that obtained with casts, but without the disadvantages of prolonged wearing of a cast. The high laced, laterally reinforced shoe permits physiotherapy and limited movement. The disadvantages of complete immobilization and trophic changes are avoided, while the ligament can be mobilized without undue strain. Extreme movements such as supination, adduction and maximal extension and flexion are prevented as effectively as with a cast. The time during which the patient is unable to work is reduced for most vocations, which also reduces insurance costs. This postoperative physiotherapy of a selected, active patient group is an effective alternative to conventional cast immobilization.     

Predictors of Return after Cast Removal in Patients with a Nonoperatively Treated Distal Radius Fracture

Patients with a nonoperatively treated fracture of the distal radius are often scheduled for a follow-up appointment after cast removal to assess function and outcome. Our experience is that, once the cast is off, many patients do not return. The purpose of this study was to determine which variables significantly influence return for a scheduled visit after cast removal. Thirty-seven patients enrolled in a prospective cohort study (27 men and 10 women) with an average age of 49?years (range, 19 to 82) had a distal radius fracture immobilized in a cast. During the visit at which the cast was removed, arm-specific disability, misinterpretation of nociception, and symptoms of depression were measured using validated questionnaires. Eleven of 37 patients did not attend the final scheduled office visit and the only predictor of a return visit was older age.     

Backslabs and plaster casts: which will best accommodate increasing intracompartmental pressures?

Plaster-of-Paris backslabs are presently used after closed or operative reduction of fractures as they are thought to accommodate any swelling which may occur. This study was designed to examine the ability of different types of cast to expand with increasing internal pressure. The results of the study show clearly that a split and spread cast is the only safe cast to use after fracture as it allows for swelling. Backslabs are no better than a complete plaster at accommodating increased internal pressure. It is therefore recommended that backslabs are no longer used to maintain reductions when swelling is anticipated.     

急性跟腱断裂治疗的新方法

跟腱断裂术后往往均用石膏固定踝关节。1995年起，作者等对急性跟腱疑合法和术后一种新的踝关节可活动石膏固定。30例新鲜跟腱断裂患者均采用跟腱4线疑合法，术后随机分成2组，新的石膏固定和传统石膏固定比较。术后随访1年，无1例跟腱再断裂，新疗法正常踝关节活动度和跖屈肌力的恢复好，腓肠肌萎缩病例数少，并发症少。     

急性跟腱断裂治疗的新方法

跟腱断裂术后往往用石膏固定踝关节。1995年起,我院对急性跟腿断裂采用一种新的跟腱缝合法和术后一种新的踝关节可活动石膏固定。30例新鲜跟腱断裂患者均采用跟腱4线缝合法,术后随机分成二组,分别采用新石膏和传统石膏固定。术后随访一年,无一例跟腱再断裂,新疗法正常踝关节活动度和跖屈肌力恢复好,腓肠肌萎缩病例数少,并发症少。     

A randomized trial of 'soft cast' for distal radius buckle fractures in children

A buckle fracture is a stable fracture where there is a dorsal cortex compression of the distal radius. A total of 117 children with buckle fracture treated at our institution were randomised prospectively into two treatment groups: soft cast or rigid cast. The rigid cast group attended clinic after three weeks for removal of the cast. In the soft cast group, the cast was removed by parents at home after three weeks. Telephone follow-up was carried out after 4 to 5 weeks post fracture. Both groups had full recovery as compared to the uninjured side and parents were satisfied with the treatment. Only one patient in the soft cast group had a problem as compared to 5 in the rigid cast group (p = 0.035, using chi square test). When given a choice, parents of children in both groups opted for future treatment with a soft cast (p < 0.01 using chi square test). Our study showed that buckle fractures of the distal radius can safely be treated with a soft cast without the need for more than one fracture clinic appointment.     

The effects of Scaphoid and Colles casts on hand function

Although necessary for bone healing, immobilisation temporarily prevents hand function and may necessitate corrective physiotherapy later. Scaphoid and Colles casts are both commonly used to immobilize scaphoid fractures. Non-union rates are comparable with both casts. The Scaphoid cast incorporates the thumb, whereas the Colles cast leaves the thumb free. We compared the effect of the two casts on hand function in 20 healthy right-hand-dominant volunteers using the Jebsen-Taylor Hand Function Test. Data were obtained through a mixed between and within subject design. Both casts prolonged the time taken to complete the hand function test compared to controls. Testing in the Scaphoid cast took significantly longer than in the Colles cast.     

Mid-third forearm fractures in children: an unorthodox treatment

Twenty children with fractures of both bones in the middle third of the forearm were immobilized in extension after closed reduction. Unlike distal-third fractures, these fractures are prone to develop rotary and angular deformities that may lead to permanent functional impairment and visible deformity. Mid-third forearm fractures with the radius fracture proximal to the ulnar fracture are even more troublesome. Nineteen patients had no clinical deformity at cast removal, and by 1 year, there was no difference in forearm rotation. Extension casting can be used initially for proximal fractures or to salvage forearms that lost reduction in flexed elbow casts. Extension cast application is easy while the reduction is maintained, whereas the problems are often encountered while applying a flexed elbow cast. This unorthodox treatment is safe and effective and may alleviate the need for surgical intervention.     

Combination of bortezomib-based chemotherapy and extracorporeal free light chain removal for treating cast nephropathy in multiple myeloma

Besides amyloidosis and light chain deposition disease, themost common histological type of renal lesion is cast nephropathyin 30% of patients with multiple myeloma [2]. In contrast toamyloidosis, cast nephropathy is believed to be potentiallyreversible when circulating light chains are rapidly reduced.We report on three patients with multiple myeloma and cast nephropathytreated with a bortezomib-based chemotherapy in addition toa newly developed high-cutoff polyflux® haemofilter. Reductionin serum free light chain levels was achieved within 10–12days, with all three patients improving their renal function.     

肝细胞癌侵入胆管致梗阻性黄疸的诊断和鉴别诊断

我院自1987至1994年收治的肝细胞癌侵入胆管致梗阻性黄疽患者28例，占同期住院肝癌患者487例的5．7％，其中癌管型13冽，癌血栓型15例。根据手术和病理学发现，癌管型特点为胆管内赘生物与原发灶呈哑铃形相连，与胆管壁无粘连，胆管壁薄，原发灶多在肝中心，邻近较大胆管，癌管型切片见肝癌组织；场血栓型特点为胆管内癌血栓与原发灶不相连，胆管可呈节段狭窄梗阻，癌血栓与胆管壁粘附，壁增厚，原发灶多在外周肝叶，血栓组织内含肝癌细胞。     

肝移植术后胆管铸型的电镜观察

目的 探讨肝移植术后胆管铸型的超微结构及其与胆道感染的关系.方法 手术过程中,无菌条件下收集11例肝移植术后患者的胆管铸型,留取标本.从留取的标本中随机抽取6例进行扫描电镜观察.结果 6例铸型表现为多种形态,在铸型中均未观察到有细菌或细菌残骸存在.结论 铸型中没有找到细菌的踪迹,胆管炎症可能不是其病因之一.     

Passage of a Sigmoid Colon Cast in a Patient With Ischemic Colitis

Colon cast passage, which is the spontaneous passage of a full-thickness, infarcted colonic segment per rectum, is a rare occurrence. The main cause is acute ischemic colitis resulting from a circulation compromise. Most of the colon cast cases reported were secondary to abdominal aortic aneurysm repairs or colorectal surgery. We report a case of an 80-year-old woman with ischemic colitis who excreted a 20-cm colon cast. In most cases that involve a colon cast containing a muscle layer component, invasive therapy is required owing to colonic obstruction or stenosis. However, in the present case, the colon cast consisted only of a mucosa layer and was not associated with severe stenosis or obstruction; therefore, it was successfully treated by conservative therapy. Histologic examination of the colon segment may be crucial in determining the appropriate treatment.Key words: Colon cast, Ischemic colitis, EndoscopyColon cast passage, which is the excretion of a full-thickness, infarcted colonic segment per rectum, is a rare occurrence that might perplex physicians. The defecation of such a necrotic bowel segment has been observed in acute ischemic colitis caused by a circulation compromise. Most of the colon cast cases reported were secondary to abdominal aortic aneurysm repairs or colorectal surgery. Herein, we report our experience with a patient presenting with ischemic colitis, who spontaneously passed a sigmoid colon cast. We also review 22 previously reported colon cast cases.