Serial Casting dr martin nearpod

soft tissue tightness

the muscle reaches maximal tension with less elongation

contracture causes

• prolonged immobility in shortened position

• imbalance of muscle power (spasticity)

contracture occurs more quickly in ____ muscles

innervated

spasticity

muscular hypertonicity characterized by a velocity dependent increased resistance to stretch

typically caused by damage to the part of the brain or spinal cord that controls voluntary movement

spasticity interferes with voluntary movement which can negatively affect functional skill

passive stretching

treatment approach to restore ROM when range is limited by the loss of tissue elasticity

more useful with acute injuries or when there is limited increase in tone

passive lengthening

a technique use by holding a limb in desired position at sub maximal range

achieved through casting

allows for changes in the muscles at the physiological level

changes in sarcomere distribution &/ or increase in muscle or tendon length

serial casting

procedure used to improve muscle length by providing prolonged positioning and re applying casts that gradually increase ROM until the desired ROM is met or range has plateaued

placing shortened muscle in a stretched position for a prolonged period of time to increase length in muscle

often done in series of casts

purposes of casting

• increase ROM for positioning, functional use, weight bearing

• prevention and/or maintenance of joint contractures

• decrease the need for surgical intervention of contractures

• achieve temporary decrease in muscle tone

general inclusion criteria for serial casting

• decreased ROM

• persistant hypertonicity/ spasticity

• poor joint alignment

• shortened soft tissue, nerves, vessels, ligaments

• risk of further deformity

• extremity cannot be controlled with splinting alone

• significant difference between point of initial resistance and max endpoint of range

precautions of serial casting

• allergies or prior skin reactions to casting materials

• decreased sensation

• poor communication

• excessive swelling

• sensory issues that may impact tolerance to wearing (ie tactile)

• decrease compliance with other treatment or interventions

• healing of recent fracture

contraindications/ exclusion criteria for serial casting

• poor skin integrity/ open wounds

• HTN or increased ICP

• uncontrolled autonomic storming

• marked edema in extremity to be casted

• poor bone density in extremity to be casted

• need limb access for monitoring vital signs or medication administration

• impaired circulation on recent DVT in limb

• fixed contractures

serial casting protocol

apply casts in series

once cast is applied - leave on for 3-7 days (10 max)

once full ROM is achieved or ROM plateaus the process is over

fabricate a splint or bivalve to maintain ROM

when cast is removed…

• reassess ROM

• check skin for areas of increased pressure (redness) and/or blisters (beginning of skin breakdown)

• clean the skin

• if skin check is clear apply new cast

precautions after cast application

• discoloration of hand or nail bed

• decreased pulse at distal points from cast

• cool/ cold hand in comparison to non casted side

• pain or paresthesia

• swelling in or above cast

• change in mood/ sleep pattern

• change in capillary refill

• wetness, cracks, dents, bad odor

• redness or chafing

• slipping or increased movement in cast

• increased complaints of itching

bivalve

made from final cast, casts cut into two halves and velcro straps added

after casting

splints

can be fabricated or purchased after casting

maintaining rom after casting

bivalve or splints

wear schedule

educate patient/ family

ROM exercises

rationale for soft case

in case of emergency family can remove cast at home, avoid return to clinic or ED

family can remove cast prior to returning for next cast. allows time to clean skin and work through initial cast stiffness prior to re-casting

removal process less traumatic

cons for soft cast

takes longer to harden, so if position is hard to hold it can be challenging

cast is less rigid than fiberglass = higher risk of dents

material can be too soft to hold position against high tone/ significant posturing - need to reinforce cast which takes more time

fiberglass cast rationale

cast is very strong and position can be maintained in patient with high tone or significant posturing

patient can walk in LE cast as soon as it dries

casting procedure relatively uncomplicated

cons of fiberglass

OP: costly needs to be on call in case of emergency cast removal after OT/PT hours

IP: medical team does not want to take responsibility for emergency cast removal after OT/PT hours

cast removal can be stressful (use of saw)