Chapter 4: Cast and Splint Immobilization, Remodeling and Special Issues of Children's Fractures

Matthew Halanski, Blaise A. Nemeth, Kenneth J. Noonan

Chapter Outline

Introduction

The last several decades have seen amazing enhancements in the management of adult orthopedic trauma; one of the most significant is the ability to operatively reduce fractures and to stabilize them safely with internal implants. These methods have resulted in less reliance on fracture manipulation and stabilization with external devices such as traction, splint and cast immobilization. Gone are the days of extended skeletal traction and spica cast application for adult femur fractures; tibia shaft fractures in adults are rarely treated with time-honored methods of reduction in the emergency ward, long leg cast application followed by months of patellar tendon bearing and short leg cast and splint application. Although still used with some frequency in adult trauma, upper extremity cast and splint application is often considered temporary until definitive internal fixation. 
Parallel to changes in fracture management, medicine has seen similar changes in medical education as well as who delivers certain health care. For instance, as a result of specialization, many adult orthopedists manage less trauma, rarely place casts and even more rarely will they educate residents in the safe and effective use of these methods. As reimbursement for health care changes, orthopedic surgeons are called to do those things that only they can do … operate; many other aspects of patients' care are assumed by advanced practitioners such as NPs or PAs or other allied health specialists. In many emergency rooms and in most outpatient clinics, the patient who requires definitive cast immobilization will usually have these applied by cast technicians or nurses. As a result, large fracture clinics where orthopedic residents learn from senior residents or faculty to manage fractures with casting are replaced by cast technicians while residents learn who needs operations and how. 
To a lesser degree and similar to adults, decades of advances in imaging and development of appropriate operative methods and implants have also benefited pediatric patients with orthopedic trauma. Despite wide changes in adult trauma, cast and splint methodology is used with great frequency in the management of pediatric trauma. In children, requisite attention to perfect reduction and extensive immobilization is not needed because of the rapidity of fracture healing and the remodeling potential seen in children. Greater than 90% of adult forearm fractures are treated with surgery; in children, 90% of forearm fractures are treated with reduction and cast immobilization. 
In this textbook, organization of information is largely based upon anatomic location of trauma and fractures. Within each of these areas, attention is directed toward both operative and nonoperative methods of treatment. The purpose of this chapter is to review in detail the methods and pitfalls of nonoperative treatment that are common to all areas of pediatric trauma. In addition, we will review unique characteristics of children that are also of importance in all fracture locations and trauma. It is desired that this chapter, its figures and video clips will serve as a primer of pediatric orthopedic trauma. As such we have included 15 fractures that can be underappreciated and at risk for management error; extensive illumination of these fractures will be found in other chapters. 

General

Because of the growth and remodeling potential of pediatric bones, acceptable alignment rather than exact anatomic reduction is sufficient for many fractures, allowing the majority of pediatric fractures to be managed in a cast. Similarly, joint stiffness is not typically a long-term problem in children treated in a cast.7 The goals of pediatric cast treatment are to protect and provide stability to the broken bone, maintain alignment, and protect from further injury until sufficient healing has occurred. In general the alignment maintained in the cast should allow the child to eventually remodel to anatomic “normal” by the cessation of growth. The younger the child, the more malalignment may be acceptable. Likewise, deformity closer to the growth plate and in the plane of motion will typically remodel more than those elsewhere. 
The duration of cast treatment is both age and site specific. Very young children, infants, and newborns will generally heal fractures quicker than adolescents. In general, fractures of the hands and feet require 4 weeks of immobilization; elbow fractures 3 to 6 weeks; tibial shaft fractures may take 12 to 16 weeks, whereas most other fractures require 6 weeks. Before discontinuing cast immobilization, fracture healing should be documented on radiographs and the child nontender at the fracture site. 
In general, casts are utilized to maintain alignment. If a fracture is nondisplaced or has an acceptable alignment, the cast's purpose is to maintain that alignment until the bone has healed. If a fracture has an unacceptable alignment, it should be reduced to an acceptable alignment and the cast placed to maintain that alignment. Fractures that should be treated operatively include injuries in which adequate alignment or length cannot be easily obtained or maintained, displaced intra-articular fractures, and many fractures involving the physis. Postoperatively the limb may be protected with a splint or a cast if necessary. Problems may arise when a cast is used to obtain acceptable alignment. Pressure sores and soft tissue injuries have been documented when casts are used in this manner and should be done so with caution.59,72,97 
To minimize motion at the fracture site, casts are placed to span the joint proximal, distal, or both. In general, the more proximal a fracture, the more likely joints at each end of the bone will be spanned. Increasing the length of the cast increases the resistance to rotation.57 To maintain correct alignment, limbs may be casted in different positions to counteract specific displacing forces on the proximal or distal fragment of a given fracture. For example, in a subtrochanteric femur fracture, the proximal fragment is pulled into flexion, abduction, and external rotation by attached muscles, so the distal fragment must be positioned with this in mind. 
Fractures treated in casts should be followed with radiographs. Some controversy may exist in the necessity of obtaining repeat radiographs of nondisplaced wrist fractures; however, scheduled follow-up of displaced fractures should be performed. It is prudent to follow fractures that required reduction weekly for 2 to 3 weeks to recognize if displacement occurs in time for re-reduction to be performed before healing is too far along. Some fractures such as lateral condyle fractures of the humerus or tenuous reductions of the forearm may require weekly radiographic evaluation for 3 weeks or more until early callus is observed. Late radiographic follow-up between 6 and 12 months should be considered for any fracture involving the growth plate with risk for growth arrest or in fractures in which overgrowth is a concern. 

Cast Complications

Although casting is often viewed as “conservative” treatment, the treating physician and family should recognize that this does not imply that this treatment is without complications. Although the true incidence of cast complications is unknown, a litigation history of a large multispecialty multilocation pediatric group showed that casts were the number one cause of litigation. Over 25% of children treated in a hip spica cast have been shown to have skin complications.27 Over a 5-year period at one institution, 168 unplanned visits to the emergency room were because of cast issues. Twenty-nine percent of these visits were for a wet cast, 23% for a tight cast, and 13% for a loose cast.86 Over a 10-year period, Physicians Insurers Association of America (PIAA) reported 1,023 claims on problems of immobilization and traction for which 16% of all claims had an associated issue including failure of consent. This implies that many physicians and patients may expect cast immobilization to be without risk. Thus, it is important to inform patients and their caregivers of the risks associated with cast treatment. When the risks of treatment are given, it is beneficial that these risks be written and delivered to the patient and their family.51 

The Wet and Soiled Cast

Wet casts that are not made with synthetic material and waterproof liners (and thus can dry quickly) should be changed. Failure to do so may result in skin irritation, breakdown, and possible infection. Light moisture or spotting may be dried with a hair drier on cool or low heat, with instructions to check the temperature of the dryer with their hand to ensure that it is not too warm. A frankly wet cast or cast padding that cannot be dried as described above usually requires inspection of the skin and cast change68 (Fig. 4-1). Although the majority of limbs in these casts will only demonstrate skin maceration,27 serious life-threatening complications such as toxic shock syndrome and necrotizing fasciitis have been reported.25,73 Hip spica casts are often applied in the operating room and their removal and exchange at times require a general anesthetic. Parents should be well instructed on positioning to avoid soiling, frequent diaper changes, and inspecting the children for skin irritation. Anesthetic risks must be weighed with the perceived soft tissue and skin risk. 
Figure 4-1
Examples of dermatitis related to wet casts.
 
A: A soiled hip spica cast. B: Upper extremity cast that was wet. (Property of UW Pediatric Orthopaedics.)
A: A soiled hip spica cast. B: Upper extremity cast that was wet. (Property of UW Pediatric Orthopaedics.)
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Figure 4-1
Examples of dermatitis related to wet casts.
A: A soiled hip spica cast. B: Upper extremity cast that was wet. (Property of UW Pediatric Orthopaedics.)
A: A soiled hip spica cast. B: Upper extremity cast that was wet. (Property of UW Pediatric Orthopaedics.)
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Thermal Injury

Plaster and fiberglass, the two most common casting materials, harden through exothermic chemical reactions. Plaster has a much higher setting temperature than fiberglass and therefore a higher risk for thermal injury when a cast is placed. Two factors strongly associated with thermal injuries are dip water temperature and the thickness of cast material. Several studies have shown that risk of thermal injury is significant if the dip water temperature is too hot (>50°C) or if the casts are too thick (>24 ply).39,46,61 Each plaster manufacturer has recommended dip water temperatures that should not be exceeded. Using warmer temperatures to “speed up” the setting time beyond those recommended should be avoided. Casts in excess of 24 ply are rarely encountered; however, increased amounts of casting material are often placed in the concavities of extremities (antecubital fossa and dorsum of the ankle) because of material overlap.46 Incorporating splints on the convexity thus decreasing overlap in the concavity can minimize this. Similarly, clinicians placing plaster splints of 10 to 15 ply on an extremity may breech safe thicknesses when the splint is too long and the edges are folded over thus creating a focal area of 20 to 30 ply, a thickness at which temperatures do become a risk.46 Studies have shown that temperatures high enough to cause significant thermal injuries can also be reached when the clinician places a curing cast on a pillow.39,46 The practice of reinforcing a curing plaster cast with fiberglass may place the limb at significant risk because the synthetic overlap prevents heat from effectively dissipating, as well as an increased risk of case burns at removal in our experience. The plaster must be allowed to cure before setting the casted limb on a support or applying fiberglass reinforcement. Failure to wait may place the insulated portion of the limb at significant risk.46 Case reports demonstrating this potential complication do exist.9 Those patients undergoing regional or general anesthesia may be at increased risk as they will not report thermal injury. 

Areas of Focal Pressure—Impending Pressure Sores

A key to preventing loss of fracture reduction is in the application of a well-molded cast. “Well molded” means casts should closely mimic the limb they are immobilizing. Cast padding should be applied between 3 and 5 layers thick over the limb being casted.71,88 Bony prominences and cast edges should be additionally padded to prevent irritation yet allow a cast to be molded to fit snugly without undue pressure. The heel, malleoli, patella, ASIS, and olecranon, are areas that may require additional padding. The use of foam padding in such areas may help decrease the incidence of pressure sores.35 
If areas of increased pressure are formed, they may lead to foci of decreased perfusion and result in pressure sores. Similarly, great care should be taken in preventing a change in limb position between application of the cast padding and the casting material. A common example is a short leg cast applied in less than 90 degrees of ankle flexion; if the ankle is flexed to 90 degrees during the application or curing of the cast, the material will bunch up and will impinge on the dorsum of the ankle. 
Families and patients should be instructed to refrain from placing anything between a cast and the patients' skin. Often this is done to alleviate pruritus but should be avoided as inadvertent excoriation may occur. Despite these warnings, food, toys, writing utensils, money, and other items have been found down casts, and we have seen them erode through patients' skin. Numerous case studies report problems from foreign bodies placed down casts.12,94 Any patient with a suspected foreign body down their cast should have the cast removed and skin inspected (Fig. 4-2). 
Figure 4-2
Examples of foreign bodies found under splints/casts.
 
A: A bracelet that was not removed prior to immobilization. B: A plastic knife which was found down a lower extremity cast. C: A coin found down a long-arm cast. D: A toy tank found under a cast. (Property of UW Pediatric Orthopaedics.)
A: A bracelet that was not removed prior to immobilization. B: A plastic knife which was found down a lower extremity cast. C: A coin found down a long-arm cast. D: A toy tank found under a cast. (Property of UW Pediatric Orthopaedics.)
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Figure 4-2
Examples of foreign bodies found under splints/casts.
A: A bracelet that was not removed prior to immobilization. B: A plastic knife which was found down a lower extremity cast. C: A coin found down a long-arm cast. D: A toy tank found under a cast. (Property of UW Pediatric Orthopaedics.)
A: A bracelet that was not removed prior to immobilization. B: A plastic knife which was found down a lower extremity cast. C: A coin found down a long-arm cast. D: A toy tank found under a cast. (Property of UW Pediatric Orthopaedics.)
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A loose cast may result in a loss of reduction or skin sores as a result of shear forces repeatedly applied to the limb. One may rationalize that the best way to avoid pressure sores is to increase the amount of padding under the cast. Injudicious application of excessive padding can lead to a cast that is too loose and paradoxically increase the risk of skin irritation from sheer stress at the skin/padding interface. Loose-fitting casts can be further associated with fracture malunion because of loss of reduction.48 In such cases, the distal fingers or toes are often noted to “migrate” proximally when this occurs and should alert the parent and the clinician that there is a problem. This has been termed the “disappearing toes/fingers sign.”99 It is during this migration that pressure sores may occur as the limb migrates proximally in a fixed cast. This causes a mismatch in the shape of the cast and the shape of the limb. In a lower extremity cast, which migrates distally, the dorsum of the foot receives pressure from the anterior ankle crease of the cast, while the heel is pulled up and rests along the posterior calf portion of the cast. Prolonged positioning in such a manner may result in pressure sores. 

Detecting Cast Complications

That “there are no hypochondriacs in casts” is an important aphorism to remember and every effort should be taken to resolve the source of complaint in an immobilized patient. Any reports of casts getting wet, soiled, or questionable foreign bodies being lost down casts should be taken seriously and the patient evaluated in a timely manner. A complication of casting should be considered whenever an immobilized patient has an unexplained increase in pain, irritability, or unexplained fevers.25 
Some cast complications such as soiling and wetness can be detected on physical examination, whereas others may be more difficult to diagnose. A foul-smelling cast may be a sign of wound infection and the cast should be removed or windowed to be inspected the source of the smell. Pressure sores may be diagnosed if the patient can localize an area of discomfort away from the fracture or operative site. Complaints of pain in high-risk areas such as the heel, dorsum of the foot, popliteal fossa, patella, olecranon, must alert the clinician of an impending problem. However with pediatric patients, localization may not be possible. One must correlate history, the clinical examination findings, such as the “disappearing toes sign” with radiographs. These images can be used to critically evaluate not only the alignment of the fractured bone, but also the outline and contour of the cast padding and material, especially in the antecubital, the popliteal fossae, and over the dorsum of the foot. If there is a suspicion of a problem, the cast should be windowed or removed and the area inspected. 
Certain pediatric patients may be at a higher risk for cast complications. These include patients with an inability to effectively communicate. The very young, developmentally delayed, or patients under anesthesia or sedation may have difficulty responding to noxious stimuli such as heat or pressure during the cast application. Discerning problems in this group may be quite difficult and cast sores can occur despite appropriate and careful application. 
Similarly, patients with impaired sensation are at increased risk for injuries related to excessive heat and pressure. In this group are those with spinal cord injuries,80,89 myelomeningocele,66 and systemic disorders such as diabetes mellitus.43 Furthermore, prolonged immobilization in many of these marginally ambulatory patients will potentiate existing osteopenia, thus, increasing the risk of fractures and need for further immobilization. 
Patients with spasticity are also at increased risk for complications. Often these patients have multiple risk factors including communication difficulties and poor nutrition in addition to their spasticity. These factors place them at particular risk for developing pressure sores.63,91 

Treating Cast Complications

Dermatitis

The majority of dermatitis under casts has to do with maceration of the skin and continued contact with wetness including fluids such as urine or feces. Often removal of the cast, cleansing of the skin, and allowing the skin to “dry out” is all that is required. Some recommend applying over-the-counter skin moisturizers.27 If fungal infection is suspected, half-strength nystatin cream and 1% hydrocortisone cream may be applied followed by miconazole powder dusting twice daily.27 If unstable, the fracture may be managed by a newly applied dry split cast or splint allowing time for the skin to recover. In rare cases internal or external fixation may be chosen to manage the fracture and to allow treatment of the skin issues. Often the skin will improve dramatically after a few days and a new cast may be applied. If significant concern for cellulitis exists, such as induration or fevers, laboratory tests should be ordered and empiric oral antibiotics prescribed. 

Pressure Sores

Pressure sores are the result of a focal area of pressure, which exceeds perfusion pressure. Although there may be initial pain associated with this pressure, this can be difficult to separate from the pain of the fracture or surgery. Any pain away from the injured area should be suspected to have a problem with focal pressure. The heel is the most common site. These sores may vary from areas of erythema, to black eschars, to full thickness soft tissue loss and exposed bone (Fig. 4-3). In the benign cases removal of the cast over the heel and either cessation or careful reapplication is all that is necessary. Typically black eschars imply partial to full thickness injuries. If they are intact, nonfluctuant, nondraining, and mobile from the underlying bone they may be treated as a biologic dressing with weekly wound checks. If any concern exists, a “Wound Team” and/or Plastic Surgery consult should be sought earlier rather than later. Often dressing changes utilizing topical enzymatic ointments and antibiotic ointments can be used to treat these wounds (Fig. 4-4). Whenever exposed bone is present, osteomyelitis is a concern requiring aggressive intervention and possible intravenous antibiotic therapy. In these severe cases vacuum-assisted closure (VAC) therapy, skin grafting, or flap coverage may be necessary.62 
Figure 4-3
Examples of heel pressure sores.
 
A: Mild erythema and superficial skin damage, (B) intact eschar, (C) partial/full thickness injury with exposed bone and fascia. (Property of UW Pediatric Orthopaedics.)
A: Mild erythema and superficial skin damage, (B) intact eschar, (C) partial/full thickness injury with exposed bone and fascia. (Property of UW Pediatric Orthopaedics.)
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Figure 4-3
Examples of heel pressure sores.
A: Mild erythema and superficial skin damage, (B) intact eschar, (C) partial/full thickness injury with exposed bone and fascia. (Property of UW Pediatric Orthopaedics.)
A: Mild erythema and superficial skin damage, (B) intact eschar, (C) partial/full thickness injury with exposed bone and fascia. (Property of UW Pediatric Orthopaedics.)
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Figure 4-4
 
Picture of heel ulcer at clinical follow-up after operative debridement (A). After roughly 2 months of topical enzymatic and antibiotic treatment with dressing changes (B). (Property of UW Pediatric Orthopaedics.)
Picture of heel ulcer at clinical follow-up after operative debridement (A). After roughly 2 months of topical enzymatic and antibiotic treatment with dressing changes (B). (Property of UW Pediatric Orthopaedics.)
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Figure 4-4
Picture of heel ulcer at clinical follow-up after operative debridement (A). After roughly 2 months of topical enzymatic and antibiotic treatment with dressing changes (B). (Property of UW Pediatric Orthopaedics.)
Picture of heel ulcer at clinical follow-up after operative debridement (A). After roughly 2 months of topical enzymatic and antibiotic treatment with dressing changes (B). (Property of UW Pediatric Orthopaedics.)
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Joint Stiffness and Muscle Contractures

Determination of cast immobilization duration is often multifactorial; however, the clinician must recognize that unwanted physiologic changes occur. Although these changes are less pronounced in children than adults, excessive length of immobilization may lead to problems such as stiffness,33 muscle atrophy, cartilage degradation, ligament weakening, and osteoporosis.7,14,16,38,44,52,92 This must be weighed against the bony healing gained in prolonged immobilizations. Alternatives such as Pavlik harness bracing for infants with femur fractures,75 patellar tendon bearing casts versus long leg casts for tibial fractures, short-arm casts for distal forearm fractures, and other functional braces may minimize some of the risks of cast immobilization or at least decrease the duration of cast treatment. 
The ankle, elbow, and fingers are often locations prone to stiffness. The duration of immobilization should be minimized if at all possible. In minimally displaced medial epicondyle and radial neck fractures, the limb should only be immobilized for 7 to 10 days until the patient is comfortable, but protected from further injury during activities such as contact sports for at least 3 to 6 weeks after the fracture. Similarly, once clearly established healing has occurred in supracondylar humerus fractures, the limb should be allowed motion after 3 to 4 weeks of casting. The position of immobilization is also important in the nearly skeletally mature. Placing the foot in plantar flexion, or failing to splint fingers in the safety position (70 degrees MCP flexion/IP extension) may result in joint contractures that persist long after fracture healing, though this is uncommon in young children. 

Compartment Syndrome

Most limbs with fresh fractures are more comfortable after immobilization. Therefore, increasing pain or neurovascular change should be fully evaluated to detect above complications and possibly compartment syndrome. Fractures and surgery can result in progressive soft tissue swelling that might not have been present at the time of cast application and may lead to compartment syndrome. In this scenario,86 the first intervention should be relieving the circumferential pressure by splitting the cast and all underlying padding, as leaving the padding intact has been shown to not relieve compartment pressure. Should splitting the cast fail to alleviate symptoms, cast removal should be considered. Fractures of the tibia,34,42 forearm,42 and elbow have increased risk of compartment syndrome. High-energy fractures resulting from motor vehicle accidents,34 crush injuries,2 or two-level injuries such as a floating elbow, should raise the treating physician's awareness to the possibility of an impending compartment syndrome. Any child unable to detect pain associated with compartment syndrome (a nerve injury or regional anesthesia)78 must be followed closely for the development of compartment syndrome. 
Children do not usually exhibit the classical four Ps (pallor, paresthesias, pulseless, pain with passive stretch) associated with compartment syndrome until myonecrosis has occurred. Instead the three As of increased agitation, anxiety, and analgesic requirements have been documented as the earliest signs of compartment syndrome in children. Any child exhibiting these symptoms that are not relieved with cast splitting should have the cast removed and limb inspected with a high suspicion of compartment syndrome. One should be ready to take the child to the operating room for formal compartment evaluation and decompression if needed. 
Fractures with associated neurovascular injuries are at significant risk of developing a compartment syndrome and require frequent neurovascular checks. These limbs may be stabilized with a splint as opposed to circumferential cast application; which could worsen the risk of compartment syndrome. These limbs are most often treated with operative stabilization using internal or external fixation and/or splint immobilization. This allows continued neurovascular assessment, palpation of compartments, and inspection of the limb. For instance, the child with a floating elbow fracture and associated nerve palsy (at high risk for compartment syndrome) is usually best treated with internal fixation of the fractures, and either a splint, bivalved cast that is easily opened, or cast with thick foam to allow for swelling, with the volar forearm exposed to assess the compartments as well as the pulses. 

Disuse Osteopenia and Pathologic Fractures Adjacent to Cast

Patients with paralytic conditions or cerebral palsy patients and those taking anticonvulsants may experience further disuse osteopenia with immobilization.80,89 These patients are at significantly higher risk of pathologic fracture while casted or upon cast removal.3,63 Strategies to prevent this includes minimizing immobilization (<4 weeks), weight-bearing casts, and the use of less rigid immobilization such as Soft Cast (3M Healthcare Ltd, Loughborough, England) and splints and braces. 

Delayed Diagnosis of Wound Infections

Many children are placed in postsurgical casts. The vast majority does well without incident. However, casts over wounds or pins may cause a delay in the diagnosis of a wound infection (Fig. 4-5). For instance, an estimated 1% to 4% of all pediatric supracondylar humerus fractures treated with pinning the elbow, will develop a postoperative pin tract inflammation or infection.5,33 Therefore, unexplained fever beyond the perioperative period, increase in pain at pin sites, foul smell, or discharge from a cast should be evaluated by a member of the orthopedic team. The wound should be examined either with cast windowing or cast removal. Laboratory tests including CBC, ESR, CRP are advisable. In cases of early pin site infection where the fracture is not yet healed, oral antibiotics may control the infection long enough to allow fracture healing. Infections of pins used for certain fractures may have a high chance of joint penetration (lateral condyle, distal femoral physeal, proximal humerus) and can lead to a septic joint. This is much more serious than simple pin site infections, and most often must be treated with surgical irrigation and debridement and pin removal should be considered. 
Figure 4-5
After getting a postoperative cast wet, dermatitis and possible cellulitis were found at the incision following a gastrocnemius recession.
(Property of UW Pediatric Orthopaedics.)
(Property of UW Pediatric Orthopaedics.)
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Types of Casting Materials

Before placing a cast, the limb must be inspected. Any dirt, operative skin prep, jewelry should be removed before the cast is applied. Often appropriate size stockinette or liner is applied against the skin, under the cast and cast padding. Although not essential, these liners minimize skin irritation; allow nice well padded and polished edges to the cast to be applied. They also minimize the tendency of some children to “pick out” their cast padding. These liners are made of cotton, water-friendly synthetic materials such as polyester, sliver-impregnated cotton (to minimize bacterial growth), and Gore-Tex (W.L. Gore & Associates; Newark, Delaware). Some in the care of children who require spica cast application favors water-permeable liners such as Gore-Tex. In addition to being more convenient for patients, these newer materials have been shown to minimize skin irritation.47,58,101 

Cast Padding

Different materials are used to pad the extremity between the cast material and the patient's skin. A thin layer (3 to 5 layers) of padding is applied to the portion of the extremity that is not prone to pressure sores and it is applied without wrinkles.71,88 Additional layers may be placed over bony prominences to minimize pressure in these areas. Cotton is the cheapest and is historically most commonly used. But casts with cotton padding cannot be made waterproof as the cotton padding retains water. Newer synthetic materials have variable water resistance and when paired with fiberglass can allow patients to bathe and swim. However, these materials are considerably more expensive than their cotton counterparts. In addition, some synthetic padding is less resistant to a cast saw. If one applies Gore-Tex (W.L. Gore & Associates; Newark, Delaware) padding, the blue DE FLEX safety strip (W.L. Gore & Associates; Newark, Delaware) can be placed along the path that the cast saw will take to remove the cast. 
Cast edges are often a source of skin irritation and abrasion. This is especially true for fiberglass casts. When making a cast, applying the stockinette and cast padding at least 1 cm beyond the edge of the fiberglass, and folding the stockinette and padding back over the first layer of fiberglass, will make a cast with well-padded edges. Closed cell adhesive foam may also be applied to the edges of a cast and to pad bony prominences. It is important to recognize that some foam padding will accumulate moisture and will not be effectively wicked away from the liner and skin. Should difficulty be found in folding back the underlying stockinette or liner, the cast edges may be petaled with tape or moleskin adhesive. This involves placing a 1 to 2 in piece of tape on the inside of the liner and folding the taped liner over the opening of cast. Most commonly petaling is performed on hip spica casts, but may be performed on any cast. 

Plaster of Paris

Plaster-impregnated cloth is the time-tested form of immobilization. It was first described in 1852 and has been the gold standard for cast immobilization for many years. This material is generally less expensive and is more moldable in comparison to the synthetic counterparts. The major advantages of plaster over synthetic materials in the prevention of cast sores and limb compression are its increase in pliability and its effective spreading after univalving. Inconveniences associated with plaster include its poor resistance to water and its lower strength-to-weight ratio resulting in heavier (thicker) casts. 
Plaster of Paris combines with water in the following reaction:   
In the process of setting up, the conversion to gypsum is an exothermic reaction with thermal energy as a by-product. In general the amount of heat produced is variable between each of the manufactured plasters. However, within each product line, faster “setting” plasters can be expected to produce more heat. As the speed of the reaction, amount of reactants, or temperature of the system (dip water and/or ambient temperature) increase; the amount of heat given off can cause significant thermal injury.39,46,61 The low strength-to-weight ratio may also increase risk of thermal injury as those unfamiliar with the amount (ply) of plaster to use may inadvertently use too much, resulting in a burn. 

Fiberglass

More recently, synthetic fiberglass materials have been introduced. These materials have the benefit of being lightweight and strong. In addition these materials can be combined with waterproof liners to allow patients to bathe and swim in their casts. These materials are often more radiolucent allowing better imaging within the cast. 
Risk of thermal injury is much lower and is a major advantage over plaster.46,76 However, because of the increased stiffness, some feel these casts are more difficult to mold, whereas others prefer fiberglass as the strength of the molded portion is greater. To prevent increased areas of pressure and constriction of the limb, special precautions are recommended when applying fiberglass rolls (see below).23 In addition, fiberglass is more expensive than plaster (2–2.5×). Finally, there may be a small long-term risk to those applying and removing these materials. Studies have disputed the carcinogenic risks in the manufacturing and use of fiberglass materials.37,93 

Other Casting Materials

In addition to the standard rigid casting materials of plaster and fiberglass, a less rigid class of nonfiberglass synthetic casting material is available. Although less rigid than standard casting materials, this Soft Cast (3M Healthcare Ltd, Loughborough, England) has several potential advantages. Experimental studies have shown that this material is more accommodating to increases in pressure than the other casting materials.26 As this material is less rigid, it may be an ideal material to immobilize patients with severe osteopenia. Finally, this material can be removed without using a cast saw, which eliminates the risk of cast saw injury.10 

Combination of Materials

Some combine plaster and fiberglass casting materials in hopes of obtaining the best features of both. One may reinforce a thin well-molded plaster cast by overwrapping it with fiberglass to increase its durability and minimize its weight. With this technique one must ensure that the plaster has set before overwrapping with the fiberglass. Failure to do so may result in a thermal injury.46 Shortcomings of this technique include the fact that the two layers of material may obscure fine radiographic detail. Finally, great care must be taken when removing such casts as it may be difficult to “feel” the depth of the cast saw blade and blade temperatures may be more elevated than usual. As a result of the increased risks of burns, it is especially important to use plastic protection strips under the cast when using a standard vibrating cast saw for cast removal. Yet despite these shortcomings, fiberglass has become the most popular casting material in most centers; this is because of the increased strength, decreased weight, improved radiographic quality, and ability to make water-friendly casts. 

General Cast Application Principles

Optimal cast application in children requires cooperation, or at least compliance, an issue in younger children, or those with cognitive or behavioral issues, such as autistic-spectrum disorder, who often do not understand the rationale for cast application. Anxiety is further compounded by the presence of strangers, a chaotic environment, and, if applicable, pain. Controlling all of these factors increases the chances of an appropriately fitted cast. 
While pain control and sedation are often required, other techniques are helpful for calming and distracting a child during cast application. Creating a calm environment begins with the first encounter with the child: Speak with a soft voice, sitting and placing oneself at a level at or below that of the child to present a less intimidating stature. Initial examination techniques should be soft and distant from the site of concern, progressing slowly to the area of concern. A less aggravated child prior to cast application more likely remains calm during cast application. Preparing casting materials outside of the room or out of direct visualization of the child during onset of sedation or distraction helps maintain a calm environment. 
During cast application itself, a number of approaches may prove helpful, depending on the child. While some children are “attenders,” coping better when given more information and being talked through a procedure, others are “distractors” who do better with guided imagery and distraction techniques19,83; both types of children benefit from relaxation exercises. Talking to the child and his parents helps identify the best approach for an individual child, and use of child life specialists proves extremely helpful in implementing the preferred approach.17,84 Use of television/videos, games or interactive applications on a handheld device or tablet proves useful for most any age. For infants and toddlers, soft music, toys (especially those with lights or moving parts), and some interactive applications on handheld devices help with distraction and relaxation.65 When using a cast saw for cutting the cast or cast removal, ear protection helps decrease anxiety.13 For children with cognitive, behavioral, or autistic-spectrum disorders, discussion of possible approaches with the parents reaps rewards as they have the best sense of what will be calming, as well as stimulatory, for their child. Cast saws are now available that cut with a scissor-like mechanism that make very little noise and do not become hot. Use of these saws may reduce children's anxiety. 
In general, cast or splint application consists of several critical steps. (1) Understanding the injury and development of an appropriate treatment strategy. (2) Collection of all of the needed materials. (3) Assembling the team that is required to execute the process. (4) Education and preparation of the family and the patient. (5) Performing the reduction (if needed) and immobilization (cast or splint). 
Once the treatment plan is identified; the key to successful cast application begins well before a cast or splint is applied. It is important to have ready and in easy access the needed padding (cast lining and stockinette); water (at appropriate temperature) cast material (plaster and fiberglass in rolls and reinforcing slabs) as well as needed instruments (C-arm imaging, scissors, cast saws, spreaders etc.). It is important that these are ready as cast application is a timely undertaking with materials that cure and harden in a short period and the application may depend on a short window of time available for comfort or sedation of the child. It is further recognized that all needed personnel need to be ready and this will ideally include sedation team and child life specialists in addition to the one to three people needed to apply a splint or cast. 
Several important concepts need to be kept in mind when handling plaster of Paris. This material depends on excellent handling techniques to maximize the benefits of mold ability and fit and also to maximize strength. Each practitioner will have biases on how the art of cast application proceeds in their hands. Some like the plaster to be wet to mold better, others will like a drier roll to ease application (less slippery) and speed the curing process. Within these two extremes will be a consistency that is appropriate as the plaster roll is unrolled onto the limb. It is optimal to keep the plaster roll in contact to the limb to avoid wrapping the material too tight (Fig. 4-6). The plaster should be unrolled with overlaps of ½ to ¹∕³ the width of the roll and tucks are taken to avoid the tendency of pulling and stretching the material (thus increasing tightness) to get a good distribution and fit of the plaster around the difficult concave areas of the ankle, knee, elbow, and thumb. The optimal cast technique requires frequent rubbing and incorporation (termed: Initial molding) of the plaster rolls as the cast is being applied. Constantly rubbing the plaster as the cast is applied will improve the fit but will also flatten the tucks and incorporate the mineral portion of the plaster into the fiber mesh for optimal strength. Plaster splints should be dipped and vigorously molded together before applying to the convexity of the limb (back of elbow or ankle) or where additional strength is needed (anterior knee [long-leg cast] or posterior thigh [spica cast]). 
Figure 4-6
Plaster roll is not lifted off of the cast but kept in contact during application as it is “rolled” up the extremity with an overlap of 30% to 50%.
(Property of UW Pediatric Orthopaedics.)
(Property of UW Pediatric Orthopaedics.)
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Once the plaster cast is applied and the initial molding has been accomplished, the cast must be held in a manner that maximizes reduction and prevents possibility of pressure sores. For instance it is critical that a cast is supported by broad surfaces such as the palm of a hand; the thorax of the surgeon is an excellent broad surface to hold the plantar foot in neutral flexion and extension (Fig. 4-7). Holding a cast with the tips of fingers will leave indentations that can lead to pressure sores. If fingers are needed for molding, pressure should be applied and then withdrawn as the plaster reaches the final curing at which point “terminal” molding of the cast can be done. Terminal molding is that point at which the plaster is fairly firm and warm; yet can be gently deformed without cracking the plaster of Paris. This is the appropriate time to do the final mold and hold of fracture fragments. As the cast goes through the final curing process it can be supported on pillows, provided the cast is not too hot (the pillow prevents heat loss and will increase the temperature at the skin surface). A leg cast should be supported under the calf and allowing the heel to hang free (Fig. 4-8) and thus prevent a gradual deformation of the heel into a point of internal skin pressure. 
Figure 4-7
The foot is supported on the surgeon's thorax and this holds the foot at 90 degrees while the rest of the cast is molded.
(Property of UW Pediatric Orthopaedics.)
(Property of UW Pediatric Orthopaedics.)
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Figure 4-8
While the cooled cast is supported on the pillow, the heel is allowed to hang free and thus be at less risk for deformation and a heel sore.
 
The cast is univalved with a cast saw that is supported by the surgeon's index finger. (Property of UW Pediatric Orthopaedics.)
The cast is univalved with a cast saw that is supported by the surgeon's index finger. (Property of UW Pediatric Orthopaedics.)
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Figure 4-8
While the cooled cast is supported on the pillow, the heel is allowed to hang free and thus be at less risk for deformation and a heel sore.
The cast is univalved with a cast saw that is supported by the surgeon's index finger. (Property of UW Pediatric Orthopaedics.)
The cast is univalved with a cast saw that is supported by the surgeon's index finger. (Property of UW Pediatric Orthopaedics.)
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Fiberglass material is applied and molded in a slightly different manner than plaster of Paris. Although synthetic cast material has superior strength in comparison to plaster, some believe its material properties make it harder to apply and mold in comparison to plaster of Paris. Fiberglass material should be removed from its package and dipped in water just prior to application as it will cure and harden in the air. Fiberglass is often tacky in nature and therefore increased tension is needed to unroll the fiberglass, this tension can be inadvertently applied to the limb and result in a cast that is circumferentially too tight. To avoid this, fiberglass should be applied in a stretch relaxation manner23; the fiberglass roll is lifted off of the limb (in contradistinction to plaster which stays in contact); unrolled first then wrapped around the limb (Fig. 4-9). Difficulty exists when wrapping a wide roll into a concavity (anterior elbow or ankle) as the fiberglass can only lay flat if pulled too tight. Small relaxing cuts in the fiberglass may be needed, as fiberglass does not tuck as easily as plaster of Paris. Fiberglass is not as exothermic as plaster of Paris and risk of burns is lower, yet the other principles of holding the cast as the fiberglass cures is the same as in plaster of Paris. 
Figure 4-9
The fiberglass is applied with stretch relaxation method.
 
The fiberglass is unrolled first then placed over the body. (Property of UW Pediatric Orthopaedics.)
The fiberglass is unrolled first then placed over the body. (Property of UW Pediatric Orthopaedics.)
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Figure 4-9
The fiberglass is applied with stretch relaxation method.
The fiberglass is unrolled first then placed over the body. (Property of UW Pediatric Orthopaedics.)
The fiberglass is unrolled first then placed over the body. (Property of UW Pediatric Orthopaedics.)
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Cast Splitting

Casts are cut and split to decrease the pressure the limb experiences after trauma or surgery. In general, the more trauma (either from the trauma or the surgery performed) a limb experiences, the more edema that will ensue. Thus, minimally displaced fractures can often be managed without splitting a cast, while those requiring a closed or open reduction may initially need to be managed in a split cast or one padded with thick foam. Although splitting may be done prophylactically or as symptoms develop, the experienced clinician will often choose the former to avoid having to split the cast at a later time. Prophylactic cast splitting is often performed while the child is anesthetized or sedated and while this allows for a cooperative patient, great care should be taken when doing so. One must ensure that the plaster or fiberglass has set, that is hardened and cool, and that the blade temperature remains cool throughout the splitting process. 
Decreased pressure in a limb can be obtained by cutting and spreading casts and after releasing the underlying padding. The effect of cast splitting depends on the material used, how it was applied, and whether or not the associated padding was split. Plaster cast cutting and spreading (univalve) can be expected to decrease 40% to 60% of the pressure and release of padding may increase this by 10% to 20%.8,23,40,69 Fiberglass casts applied without stretch relaxation are known to be two times tighter than those applied with plaster23 and in these cases bivalving the fiberglass cast would be needed to see similar decreases in pressure. Casts that are applied with the stretch relaxation method are among the least constrictive of fiberglass casts and therefore univalving may be sufficient as long as the cast can be spread and held open. However, many of these synthetic casts often spring back to their original position after simply cutting one side. Thus, it may be wise to use commercially available plastic cast wedges to help hold these split casts open. 
Although splitting casts is the traditional means of relieving cast tightness and allowing for swelling, use of thick foam is gaining acceptance at many centers (Fig. 4-10A, B). One of the editors uses ½-in sterile foam on most postoperative casts when concern for swelling is present. In this technique the foam is placed directly on skin, to make sure circumferential pressure is not caused by cast padding. Stockinette and cast padding are then applied, followed by fiberglass. This type of cast is not used to hold a closed reduction with cast molding, but works well for casts with internal fixation. Advantages of this cast include the strength of a circumferential cast, while allowing for swelling similar to a split cast. 
Figure 4-10
 
A and B: Foam padding is placed on skin, followed by cast padding, then fiberglass casting material. This allows for welling and provides strength, but does not hold fracture reduction. Ideally stockinette at the ends of the cast would make for better edges. (Image property of Children's Hospital of Los Angeles.)
A and B: Foam padding is placed on skin, followed by cast padding, then fiberglass casting material. This allows for welling and provides strength, but does not hold fracture reduction. Ideally stockinette at the ends of the cast would make for better edges. (Image property of Children's Hospital of Los Angeles.)
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Figure 4-10
A and B: Foam padding is placed on skin, followed by cast padding, then fiberglass casting material. This allows for welling and provides strength, but does not hold fracture reduction. Ideally stockinette at the ends of the cast would make for better edges. (Image property of Children's Hospital of Los Angeles.)
A and B: Foam padding is placed on skin, followed by cast padding, then fiberglass casting material. This allows for welling and provides strength, but does not hold fracture reduction. Ideally stockinette at the ends of the cast would make for better edges. (Image property of Children's Hospital of Los Angeles.)
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Cast Removal

Typically casts are removed using an oscillating cast saw. These saws are designed to cut the hard cast material and not soft material such as padding or skin. In one report the incidence of cast saw burns occurring with the removal of casting material was found to be 0.72%4 (Fig. 4-11). Cast removal may lead to significant morbidity and several precautions are needed. If a waterproof cast was applied using the Gore-Tex padding one must not forget to cut over the incorporated safety strips prior to removal of the fiberglass cast (Fig. 4-12A, B). These can assist in preventing injury from the saw as this type of padding is less heat resistant than the cotton padding. 
Figure 4-11
Examples of cast saw burns.
 
Initial injury photo (A) and after healing (B). C: A separate injury.
Initial injury photo (A) and after healing (B). C: A separate injury.
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Figure 4-11
Examples of cast saw burns.
Initial injury photo (A) and after healing (B). C: A separate injury.
Initial injury photo (A) and after healing (B). C: A separate injury.
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Figure 4-12
 
A: A cutaway picture showing the DE FLEX (W.L. Gore & Associates; Newark, Delaware) strip under the fiberglass casting tape. B: This strip will protect the skin from cast saw that has a propensity to cut easily through synthetic cast padding. (Property of UW Pediatric Orthopaedics.)
A: A cutaway picture showing the DE FLEX (W.L. Gore & Associates; Newark, Delaware) strip under the fiberglass casting tape. B: This strip will protect the skin from cast saw that has a propensity to cut easily through synthetic cast padding. (Property of UW Pediatric Orthopaedics.)
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Figure 4-12
A: A cutaway picture showing the DE FLEX (W.L. Gore & Associates; Newark, Delaware) strip under the fiberglass casting tape. B: This strip will protect the skin from cast saw that has a propensity to cut easily through synthetic cast padding. (Property of UW Pediatric Orthopaedics.)
A: A cutaway picture showing the DE FLEX (W.L. Gore & Associates; Newark, Delaware) strip under the fiberglass casting tape. B: This strip will protect the skin from cast saw that has a propensity to cut easily through synthetic cast padding. (Property of UW Pediatric Orthopaedics.)
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Studies have shown that increased cast thickness, decreased padding, and increased blade use result in higher blade temperatures.56 Thus, blades should be inspected and changed frequently as dull blades can increase the heat generated and potential for morbidity. Most importantly the technician who removes the cast must be well trained in the use of the saws. One common pitfall is to slide the oscillating saw along the cast thus increasing the chance of a cut or burn. Proper technique dictates that the blade be used by alternating firm pressure with relaxation into the material and then withdrawn before replacing it at a different location.88 Furthermore, the technician should intermittently feel the blade and pause during the removal process when necessary to allow the blade to cool. This is essential when cutting long casts (i.e., long leg plaster). 
Cast removal may lead to significant morbidity and several precautions are needed. Various safety shields are available; which, at the time of cast removal may be slid between the skin and the padding to prevent saw injury. To protect the skin, the cast saw must cut directly over the shield. Often times, the safety shield cannot be slid up the entirety of the cast, so extreme care must be taken in these areas where the skin is not protected. Alternatively, safety strips may be incorporated into the cast at the time of cast application. If a waterproof cast was applied using the Gore-Tex padding one must not forget to cut over the incorporated safety strips prior to removal of the fiberglass cast (Fig. 4-12). These can assist in preventing injury from the saw, as this type of padding is less resistant than the cotton padding. Finally, new advances in differing types of saws may improve the safety of cast removal. For instance, some saws with a scissor-like do not become as hot. These saws are quieter and may reduce children's anxiety. 

Cast Wedging

In a fresh fracture (usually less than 2 weeks old and prior to significant callus formation) in which initial reduction was obtained and subsequently is found to have an unacceptable loss of reduction, cast wedging of a well-fitting cast may be attempted. Many techniques for cast wedging have been described; however, the most recent description by Bebbington6 appears to be easy to apply for simple angular deformities. The radiograph of the malaligned limb is used to trace the long axis of the bone onto a sheet of paper. The paper is then cut along this line. The cut edge of the paper is traced onto the cast, matching the position of the apex of the paper with the apex of the deformity. The cast is then cut, nearly circumferentially at this level, leaving a bridge of intact plaster only at the apex. Corks or cast wedges are applied opposite this bridge, until the line transferred on the cast is straight. 
If this fails, the cast may need to be removed and the fracture either remanipulated or treated in some other fashion. Great care should be taken when performing cast wedging, especially in the tibia. The clinician needs to ensure that no excessive focal pressure is exerted at the bridge causing a pressure ulcer or nerve compression. Performing a “closing wedge” of a cast allows the bridge to be placed on the opposite side of the limb, which may be advantageous in certain circumstances, such as correcting a procurvatum or valgus deformity of the tibia. A disadvantage of a “closing wedge” is that it may pinch soft tissue. After performing a cast wedging, it is wise to observe the patient in the clinic long enough to reasonably ensure that any pain associated with the correction has abated and no pain because of focal pressure exists. If any concern exists, a new cast should be applied or a different treatment course taken. 

Casting Over Surgical Wounds and Implants

Often casts are applied over surgical wounds. While the majority of these heal uneventfully, special attention should be given to casts applied over traumatic or surgical wounds. When applying a stockinette over a surgical wound, care should be taken to ensure the dressing is not “bunched up” under the liner. It is vitally important that wounds should not be dressed with circumferential cotton gauze as they may become constrictive with dried blood over time and act as a tourniquet. We prefer to use sterile cast padding, which is able to stretch with swelling and limit the gauze directly over the wound itself. Applying nonstick dressings directly to the wound aid in decreasing the anxiety of wound inspection during the cast removal process. Should unexplained pain, fevers, foul odors, drainage, or worsening pain occur; wounds should be inspected; however without these, routine inspection is not often necessary. 
Bending the exposed ends of pins under a cast prevents excessive migration and allows for easy removal; however, migration of the bent end of the pin can occur. Sterile felt or antibiotic dressing may be placed at the pin site to help provide mechanical protection of soft tissue from migrating pins. Be aware that pin caps may become displaced and cause pressure sores. Cast padding should be placed over the pins to prevent them from sticking to the casting material as it hardens. 
Although the technique of pins and plaster has largely disappeared from adult orthopedics, it can be used occasionally in pediatric orthopedics. In this technique, a fracture is reduced using pins that are placed percutaneously and incorporated into a cast to act essentially as an external fixator. The pin sites should be managed as any other exposed pin with an antibiotic dressing and/or sterile felt at the pin/skin interface. This technique allows the pins to be removed when callus formation is observed without removing the entire cast. 
To inspect any area of concern under a cast, the cast can be removed, split, or windowed. The process of windowing involves localizing the area of concern and removing the overlying cast in this area without disrupting the alignment of the underlying bone. One may consider removing this window as a circular or oval piece to avoid creating any stress risers in the cast that may alter its structural integrity. However, attempting to cut “curves” with an oscillating saw places torque on the blade, increases blade temperature. These factors should be remembered when windowing a cast. Once the cast and padding materials are removed, the wound can be inspected. Once satisfied, equal depth of padding should be replaced over the wound and the window replaced. It may be taped in place if serial examinations are required or it may be overwrapped with casting tape. Failure to replace the window can lead to swelling through the window aperture. 

Medical Comorbidities That Affect Cast Care

Even with application of a “perfect” cast, numerous medical issues may complicate tolerance of casting or lead to complications.45 Children with myelomeningocele are susceptible to a number of casting complications. Pressure sores commonly occur in insensate children who do not experience or exhibit discomfort when irritation arises under the cast. Caution should be taken to avoid areas of increased pressure or overmolding when casting. In addition, the many fractures in children with myelomeningocele result from casting used for immobilization following elective surgery.66 Iatrogenic fracture risk can be minimized by utilizing casting for as short a time frame as possible and/or use of a soft fiberglass casting material or a soft, bulky dressing that creates less of a stress riser on the bone.66 Children with cerebral palsy are also at increased risk for pressure sores.91 The contractures that likely contributed to the fracture may make casting or splinting difficult.77 Similar approaches may be considered in children with malnutrition, renal osteodystrophy or other bone fragility disorders. An additional consideration in cases of malnutrition and diminished bone health includes increased duration of fracture healing that may require longer periods of protection to prevent refracture.29 
Children with obesity present their own complications. Although there are no studies documenting the outcomes of casting in obese children, studies on surgical treatment have demonstrated complications of refracture, wound infection, and failure of surgical fixation,64,98 issues that likely have nonoperative correlates. Loss of alignment when adequate molding cannot occur because of increased soft tissues can occur. When casting an obese child, inclusion of an extra joint above and/or below the fracture may be required to maintain cast position. Diligent monitoring of alignment allows intervention with recasting, wedging, or transition to surgical intervention. Obese patients are more likely to undergo surgical treatment, as opposed to closed reduction, although it is unclear whether this is related to fracture severity or concerns regarding fracture stabilization.81 
Alterations in casting materials or approaches may also be necessary in children with behavioral issues. Children with autistic-spectrum disorder present additional complexity during cast application (see discussion on distraction techniques), but even prior to cast application considering their behavior guides decision making regarding the most appropriate immobilization. Children with violent tendencies pose even more risk once a cast is applied, not only to others but also themselves. Administration of behavioral medications may improve tolerance of casting.18 Soft splinting may be preferable, accepting some risk of malunion over likely secondary injury. Discussion and shared decision making with the parents result in the best management for an individual child and her family. 
Children with dermatologic conditions require other considerations when deciding on best methods of immobilization. Children with atopic dermatitis may react to synthetic padding, so cotton may be more preferable. Splinting allows for better skin management, but when casting is required, minimizing duration or performing frequent cast changes allows for monitoring of skin conditions or early transition to splinting. Soft casting material contains diisocyanate which has been suspected, but not proven, as a skin irritant in isolated cases60; avoiding such material in children with significant skin sensitivity or disorders seems prudent. Windowing the cast over an area of skin breakdown or infection allows for monitoring of the area. Varicella presents an even more complex issue as widespread skin breakdown occurs predisposing to superinfection. Casting helps prevent skin breakdown by covering itchy lesions, but monitoring lesions is not possible. Again, splinting may be preferable to allow for monitoring if it does not compromise maintenance of fracture reduction; otherwise, windowing, or frequent cast changes may allow for skin monitoring. There should be a low threshold for removal of the cast if the child complains of pain to assess for not only compartment syndrome or infection, but also necrotizing fasciitis.20,25 

Location-Specific Immobilization

Sugar-Tong Splint Immobilization

Sugar-tong splints provide effective temporary support to the wrist and forearm until definitive reduction and casting or internal fixation, while allowing for swelling. Sugar-tong splints can be used for definitive treatment provided the splint is comfortable and is retightened after 3 to 5 days to accommodate the decrease in swelling. At that point reapplication of an elastic bandage or overwrapping with fiberglass is appropriate. 
Before treating, the contralateral uninjured limb may be used as a template to measure and prepare an appropriate slab of casting material which should be wide enough to fully support the volar and dorsal surfaces of the arm (without radial and ulnar overlap) and long enough to span the arm from the volar MP flexion crease in the hand, around the elbow (flexed at 90 degrees), and dorsally to the metacarpal heads (Fig. 4-13). It is important that plaster splints are no more than 10 layers thick and of appropriate length so that edges do not have to be folded over (increasing thickness and the heat from curing). The slab is further customized to cut out material around the thumb base and tuck cuts are made at the elbow to prevent bunching of the material during the application. 
Figure 4-13
The plaster roll for the sugar-tong splint is measured and is chosen to be wider than the arm without allowing for overlapping once the plaster slab is dipped and applied.
(Property of UW Pediatric Orthopaedics.)
(Property of UW Pediatric Orthopaedics.)
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The injured arm is reduced and positioned as described above, it is wrapped with three to four layers of cotton padding from the hand and around the elbow (similar thickness as that used for long-arm casting). The slab is dipped in cool water, excess water is removed and the material is rubbed and the layers incorporated for strength. The ends of the slab have two to three layers of padding applied which will fold back and make the edges soft (Fig. 4-14). The splint is applied and held with one roll of cotton and then an elastic bandage is tightly applied until the material is hardened (Fig. 4-15) and then the bandage is replaced with a new elastic bandage applied without significant tension (Fig. 4-16). This method ensures an optimal fit without having the splint be too tight. 
Figure 4-14
After dipped and applied, the slab is held on by one layer of cotton while tucks are cut in the plaster at the elbow to allow for overlap and minimal bunching.
(Property of UW Pediatric Orthopaedics.)
(Property of UW Pediatric Orthopaedics.)
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Figure 4-15
An elastic bandage is wrapped tightly to assist with terminal molding of the splint.
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Figure 4-16
The elastic bandage has been removed and replaced with a self-adherent elastic tape that has been loosely applied.
(Property of UW Pediatric Orthopaedics.)
(Property of UW Pediatric Orthopaedics.)
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In the method described above, the arm is circumferentially wrapped with cotton and then a slab of plaster with padded ends is applied over it. This method is advantageous in ensuring a smooth interface of cotton without bunching under the plaster slab. If the clinician fears a lot of circumferential cotton padding could worsen swelling; an alternative method exists. In this instance, a long strip of padding is made by layering three to five layers of cotton and then the plaster slab is laid on top of it. The cotton is long and wide enough to ensure that there are no rough edges. The padded slab is then applied and wrapped as described above. 

Long Arm 90-Degree Cast Immobilization

Case study 1: A 7-year-old girl with a both bone forearm fracture undergoes attempted closed reduction and long-arm cast application. She presents to clinic the following day where radiographs reveal angulation of 18 degrees in the AP plane and 5 in the lateral plane (Fig. 4-17AD). Critical review of this case demonstrates a cast applied with too much padding and thus a poor fit, is too short in the long-arm portion, has too much plaster applied throughout the cast and especially in the antecubital fossa (increased risk for burn), and has a curved ulnar border that allows the arm to settle into the angulation. She is indicated for cast removal and re-reduction. 
Figure 4-17
A 6-year-old girl with a both bone forearm fracture.
 
Clinical pictures demonstrate a huge cast that does not adequately immobilize the elbow (A, B). AP (C) and lateral (D) demonstrate a poorly fitting cast with ulna bow, excessive padding, too much plaster in the elbow flexion crease, and a resultant poor reduction. (Property of UW Pediatric Orthopaedics.)
Clinical pictures demonstrate a huge cast that does not adequately immobilize the elbow (A, B). AP (C) and lateral (D) demonstrate a poorly fitting cast with ulna bow, excessive padding, too much plaster in the elbow flexion crease, and a resultant poor reduction. (Property of UW Pediatric Orthopaedics.)
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Figure 4-17
A 6-year-old girl with a both bone forearm fracture.
Clinical pictures demonstrate a huge cast that does not adequately immobilize the elbow (A, B). AP (C) and lateral (D) demonstrate a poorly fitting cast with ulna bow, excessive padding, too much plaster in the elbow flexion crease, and a resultant poor reduction. (Property of UW Pediatric Orthopaedics.)
Clinical pictures demonstrate a huge cast that does not adequately immobilize the elbow (A, B). AP (C) and lateral (D) demonstrate a poorly fitting cast with ulna bow, excessive padding, too much plaster in the elbow flexion crease, and a resultant poor reduction. (Property of UW Pediatric Orthopaedics.)
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Fracture reduction and long-arm cast application is best done in a setting where the child is adequately sedated and where enough qualified personnel can apply the cast under fluoroscopic guidance, although this may not be possible in many locations. Fracture reduction technique may consist of: (1) Longitudinal traction; (2) manipulation recreating the deformity (Fig. 4-18); (3) reducing the fracture and placing the intact periosteum on tension; (4) three-point molding can be used in completely displaced fractures at the same level in the forearm; hand rotation is the final position to account for based on angulation. In both bone forearm fractures where the fractures are at differing levels, apex volar greenstick angulation is reduced with pronation and apex dorsal angulation is reduced with supination. It may be helpful to remember the “rule of thumb”—rotate the thumb toward the apex of the deformity aids in reduction. Thus an apex volar greenstick is reduced with pronation, and apex dorsal with supination. Optimal hand and wrist rotations can be ensured with the use of the fluoroscope prior to cast application. 
Figure 4-18
The deformity is accentuated and hyperflexion followed by reduction can allow the displaced ends to become opposed.
(Property of UW Pediatric Orthopaedics.)
(Property of UW Pediatric Orthopaedics.)
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In this instance longitudinal traction is used with an assistant while a thin layer of cotton padding is applied (Fig. 4-19). Alternatively, the fingers could be placed in finger traps with the elbow flexed just short of 90 degrees and with weights from the distal humerus. Individual strips of cotton are placed and torn with tension to fit intimately on the posterior elbow thus avoiding too much anterior padding (Fig. 4-20). Cotton is rolled high in the axilla to ensure enough padding for the proximal trimline (Fig. 4-21). After padding is applied to the entire arm a small splint of five layers of plaster of Paris is fashioned to fit into the first web space (Fig. 4-22) and then incorporated with sequential layers of plaster (Fig. 4-23); we find that this method allows for a better fit in the hand. Plaster is pushed and unrolled up the arm to the elbow (Fig. 4-6) without lifting the plaster roll off the arm unless tucks are needed in the concavity. We prefer to apply plaster of Paris or fiberglass to a limb in stages by focusing and immobilizing one joint at a time; for long-arm casts we apply and mold the wrist and forearm and we extend the cast up over the elbow after the material has hardened. Once enough plaster is applied, the initial mold to incorporate the layers is started by rubbing the arm circumferentially (Fig. 4-24). As the plaster begins to harden, terminal molding of the arm is performed under fluoroscopy by flattening the plaster over the apex of the deformity (Fig. 4-25), molding the ulnar border with the flat of the hand (Fig. 4-26), and finally with some interosseus molding (Fig. 4-27) that will make the cast flatter and less cylindrical in cross section. Fluoroscopy images are obtained as the short-arm portion hardens before extending the cast up the humerus. If acceptable reduction is apparent, the antecubital fossa is inspected closely to detect and trim back cast material which may be too high and which could lead to neurovascular compromise. Decreased pressure in a limb can be obtained by using foam underneath the cast material or by cutting and spreading casts and after releasing the underlying padding. This method of applying the cast in two stages has the potential downside of edges of the short-arm cast digging into soft tissue proximally, so this must be avoided. As the cast is extended up the humerus, a small posterior splint can be applied to elbow convexity to decrease the tendency to fill the concavity of the elbow with thick exothermic plaster. The humerus portion is molded terminally by flattening the posterior humerus and molding along the supracondylar ridges. Plain radiographs are then obtained while the child is still sedated and if alignment is good the forearm cast is univalved and spread. In general the cast should be univalved and spread on the side of the arm which is opposite the direction of initial displacement; a fracture with a propensity for dorsal displacement should be split volarly and a fracture with a propensity for volar displacement should be split and spread along the dorsal surface. After 2 weeks, the plain radiographs demonstrate improved reduction and a more improved fitting cast (Fig. 4-28A, B). 
Figure 4-19
While the limb is held reduced with longitudinal traction applied by the assistant, cotton padding is applied and overlapped by 50%.
(Property of UW Pediatric Orthopaedics.)
(Property of UW Pediatric Orthopaedics.)
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Figure 4-20
To pad the convexity of the elbow without excessively padding the concavity, cotton strips are placed and torn over the elbow to prevent cotton from bunching up in the antecubital fossa.
(Property of UW Pediatric Orthopaedics.)
(Property of UW Pediatric Orthopaedics.)
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Figure 4-21
In this instance, stockinette was not used.
 
Cotton is placed high in the axilla to have a soft edge at the proximal trimline of the plaster which will be applied more distal in the arm. (Property of UW Pediatric Orthopaedics.)
Cotton is placed high in the axilla to have a soft edge at the proximal trimline of the plaster which will be applied more distal in the arm. (Property of UW Pediatric Orthopaedics.)
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Figure 4-21
In this instance, stockinette was not used.
Cotton is placed high in the axilla to have a soft edge at the proximal trimline of the plaster which will be applied more distal in the arm. (Property of UW Pediatric Orthopaedics.)
Cotton is placed high in the axilla to have a soft edge at the proximal trimline of the plaster which will be applied more distal in the arm. (Property of UW Pediatric Orthopaedics.)
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Figure 4-22
A small plaster splint fits nicely into the web space and will be incorporated in the plaster of the forearm portion.
(Property of UW Pediatric Orthopaedics.)
(Property of UW Pediatric Orthopaedics.)
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Figure 4-23
(Property of UW Pediatric Orthopaedics.)
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Figure 4-23
This splint is incorporated with rolls of plaster moving proximally.
(Property of UW Pediatric Orthopaedics.)
(Property of UW Pediatric Orthopaedics.)
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Figure 4-24
The cast is initially molded to incorporate the fiber and plaster to make it stronger and to improve the fit.
(Property of UW Pediatric Orthopaedics.)
(Property of UW Pediatric Orthopaedics.)
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Figure 4-25
Initial molding is performed to flatten the cast with a flat surface applied over the apex of the deformity.
(Property of UW Pediatric Orthopaedics.)
(Property of UW Pediatric Orthopaedics.)
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Figure 4-26
Initial and terminal molding of the ulnar border will allow the cast to be straight and will resist ulnar sag of fracture fragments when the swelling goes down.
(Property of UW Pediatric Orthopaedics.)
(Property of UW Pediatric Orthopaedics.)
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Figure 4-27
Gentle terminal interosseus mold keeps pressure on the apex, keeps the radius and ulna apart, and flattens the cast maintaining optimal cast index.
(Property of UW Pediatric Orthopaedics.)
(Property of UW Pediatric Orthopaedics.)
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Figure 4-28
 
A: AP and (B) lateral radiographs 2 weeks after the operative procedure demonstrate excellent maintenance of reduction and early healing. (Property of UW Pediatric Orthopaedics.)
A: AP and (B) lateral radiographs 2 weeks after the operative procedure demonstrate excellent maintenance of reduction and early healing. (Property of UW Pediatric Orthopaedics.)
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Figure 4-28
A: AP and (B) lateral radiographs 2 weeks after the operative procedure demonstrate excellent maintenance of reduction and early healing. (Property of UW Pediatric Orthopaedics.)
A: AP and (B) lateral radiographs 2 weeks after the operative procedure demonstrate excellent maintenance of reduction and early healing. (Property of UW Pediatric Orthopaedics.)
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Short-Arm Cast Immobilization

It should be noted that the above description of a long-arm cast application utilizing plaster, staged casting, splints, and univalving is the traditional method of casting preferred in many centers for displaced both bone diaphyseal fractures. Alternative methods include the use of fiberglass with the stretch relax technique, which generally does not require splints or univalving. As there are now good quality, randomized prospective studies showing that distal third both bone fractures are treated equally well in short or long-arm casts, short-arm cast immobilization is appropriate for most distal radius and ulna fractures. The technique of application is similar to that presented above; however, it is important that the distal cast be oval in cross section (Fig. 4-27) and the cast index (ratio of the AP cast width to lateral cast depth) to be near 0.7. 

Long Arm–Thumb Spica Extension Cast Immobilization

Case study 2: A 6-year-old boy suffers a displaced both bone forearm fracture that is treated with long-arm cast application. Proximal and middle third both bone forearm fractures are harder to manage as there is less remodeling potential; further, when the radius is fractured proximal to the ulna one can often see more difficulty in holding the fractures reduced when the elbow is flexed. At 1 week, radiographs demonstrate loss in reduction with 30 degrees of angulation at the radius and the need for re-reduction (Fig. 4-29A, B). 
Figure 4-29
Radiographs of a 7-year-old boy with a proximal both bone forearm fracture treated in a long-arm cast.
 
The radius fracture is proximal to the ulna and this pattern is prone to loss reduction in a long-arm flexed cast as seen in this case with unacceptable alignment. (Property of UW Pediatric Orthopaedics.)
The radius fracture is proximal to the ulna and this pattern is prone to loss reduction in a long-arm flexed cast as seen in this case with unacceptable alignment. (Property of UW Pediatric Orthopaedics.)
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Figure 4-29
Radiographs of a 7-year-old boy with a proximal both bone forearm fracture treated in a long-arm cast.
The radius fracture is proximal to the ulna and this pattern is prone to loss reduction in a long-arm flexed cast as seen in this case with unacceptable alignment. (Property of UW Pediatric Orthopaedics.)
The radius fracture is proximal to the ulna and this pattern is prone to loss reduction in a long-arm flexed cast as seen in this case with unacceptable alignment. (Property of UW Pediatric Orthopaedics.)
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In this instance we plan to reduce the arm with a combination of traction, pronation, and apex pressure with fluoroscopic guidance (Fig. 4-30). Once reduced, the arm is held with longitudinal traction, proximal and distal stockinet and cotton padding is applied for a long arm–thumb spica cast in extension (Fig. 4-31). Including the thumb in this cast will fully control forearm rotation while additionally maintaining the fracture out-to-length, which is obtained during the casting under traction. To prevent pressure sores over the thumb, extra padding is placed over the radial aspect of the anatomic snuff-box and thumb. The thumb spica portion of fiberglass is placed carefully out to the tip of the thumb whilst holding the thumb in neutral abduction and opposition (Fig. 4-32). The fiberglass is applied with 50% overlap and using the stretch relaxation technique; fluoroscopy is again utilized while terminal molding of the short-arm portion is performed in slight pronation and with broad pressure over the apex of the deformity (Fig. 4-33). The upper arm portion is next applied once the forearm portion is hardened and with the reduction confirmed under fluoroscopic imaging. As the upper fiberglass hardens, a supracondylar mold is applied with the arm in gentle traction as the butt of the surgeon's hand and thenar eminence terminally molds the fiberglass (Fig. 4-34); this mold in concert with the thumb spica mold should help to maintain rotation and length of the reduction. Final trimming and finishing the edges with the previously placed stockinette is done in the hand and the palmar trimline is cut back to allow MP finger flexion (Fig. 4-35). Finally the dorsum of the cast is univalved with a cast saw to allow for swelling; with fiberglass the cut edges of the cast need to be held open with commercially available spacers (Fig. 4-36) or other such material to keep the cast from springing closed; this is in contradistinction to plaster which can remain open once a terminally molded cast is spread. Plain radiographs after 3 weeks of immobilization confirm reduction of the fracture (Fig. 4-37). 
(Property of UW Pediatric Orthopaedics.)
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Figure 4-30
The arm is rotated under fluoroscopy to identify the rotation of the hand that best reduces the fracture.
(Property of UW Pediatric Orthopaedics.)
(Property of UW Pediatric Orthopaedics.)
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Figure 4-31
The thumb spica cotton padding is applied.
 
A moderate amount of padding is applied at the dorsal radial aspect of the thumb base. (Property of UW Pediatric Orthopaedics.)
A moderate amount of padding is applied at the dorsal radial aspect of the thumb base. (Property of UW Pediatric Orthopaedics.)
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Figure 4-31
The thumb spica cotton padding is applied.
A moderate amount of padding is applied at the dorsal radial aspect of the thumb base. (Property of UW Pediatric Orthopaedics.)
A moderate amount of padding is applied at the dorsal radial aspect of the thumb base. (Property of UW Pediatric Orthopaedics.)
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Figure 4-32
Fiberglass is applied with the stretch relaxation method.
 
(Property of UW Pediatric Orthopaedics.)
(Property of UW Pediatric Orthopaedics.)
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Figure 4-32
Fiberglass is applied with the stretch relaxation method.
(Property of UW Pediatric Orthopaedics.)
(Property of UW Pediatric Orthopaedics.)
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(Property of UW Pediatric Orthopaedics.)
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Figure 4-33
Initial molding of the fiberglass is performed over the apex of the deformity.
(Property of UW Pediatric Orthopaedics.)
(Property of UW Pediatric Orthopaedics.)
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(Property of UW Pediatric Orthopaedics.)
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Figure 4-34
Supracondylar mold is applied above the elbow; this will prevent the cast from slipping down.
(Property of UW Pediatric Orthopaedics.)
(Property of UW Pediatric Orthopaedics.)
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Figure 4-35
The hand portion is trimmed back to allow finger MP flexion and the spica portion of the cast is out to the tip of the thumb, which is neutrally placed.
(Property of UW Pediatric Orthopaedics.)
(Property of UW Pediatric Orthopaedics.)
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Figure 4-36
The fiberglass cast is held open with a plastic spacer, univalved fiberglass casts tend to spring back while plaster casts tend to stay open.
(Property of UW Pediatric Orthopaedics.)
(Property of UW Pediatric Orthopaedics.)
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(Property of UW Pediatric Orthopaedics.)
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Figure 4-37
Radiographs obtained in the OR demonstrate excellent reduction and a well-fitting cast.
(Property of UW Pediatric Orthopaedics.)
(Property of UW Pediatric Orthopaedics.)
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Thumb Spica Cast Immobilization

Usual incorporation of the thumb is needed for the extension cast described above as well as carpal injuries. Some surgeons include the thumb in all short-arm casts too. Regardless it's important to ensure the thumb is well padded and casted in a neutral position thumb abduction and opposition with well-padded distal trimline. 

Shoulder Immobilization

Immobilization about the shoulder and the clavicle is somewhat limited when compared with other areas of the skeleton. Because of anatomic constraints about the shoulder it is often very challenging to gain a reduction of a bone (proximal humerus, clavicle); and it is not practical to expect that the fracture fragment to be firmly held in a reduced position. One historical exception may be the use of the shoulder spica cast for displaced proximal humerus fractures. Practically speaking this cast was challenging to apply and for the patient to wear and pediatric orthopedic trauma surgeons today would use internal fixation to maintain fracture reduction. 
Despite the difficulty encountered when attempting reduction and firmly maintaining reduction with closed means, immobilization about the shoulder is used to provide comfort in the injured child. For clavicle fractures, a figure-of-8 collar or a shoulder sling can support the shoulder. Although the figure-of-8 collar was designed to retract the shoulder posteriorly and thus potentially reduce a shortened clavicle; practically the effect is minimal and the force needed to hold the shoulder back is often a challenge to the patient. Most patients find a personal preference between figure-of-8 collar and shoulder sling which is acceptable given equal clinical results between the two. 
A proximal humerus fracture (whether treated nonoperatively or operatively) may be protected with immobilization with a sugar-tong splint. This splint is applied in stages. A slab of fiberglass or plaster is cut to a length that spans the proximal medial humerus (not too high in the axilla) and extends over the elbow and up the lateral aspect of the humerus up over the shoulder (Fig. 4-38). After dipping in water the slab is placed on appropriate padding and then applied to the arm. We find it helpful to wrap sugar-tong splints very tightly with an elastic bandage as this improves the mold and fit. The elastic bandage is removed when the splint material is hard and is replaced loosely with a new one. The common pitfalls with this type of immobilization include the medial splint edge in the axilla that is too thick or too high. In addition, when the lateral splint edge is too low and ends close to a fracture level, it does not immobilize and actually increases the lever arm forces at the fracture. This is due to the fact that the adjacent joints which are immobilized and that could normally move and decrease the length of the lever arm, cannot function as such. 
Figure 4-38
The plaster of a sugar-tong upper arm splint is folded over the shoulder and above the fractured proximal humerus fracture.
(Property of UW Pediatric Orthopaedics.)
(Property of UW Pediatric Orthopaedics.)
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Hanging arm casts can be used in proximal humerus and humeral shaft fractures. These synthetic long-arm casts are applied with the concept that gravity will act upon the humerus fracture and can be effective in gradually improving alignment in children with fractures that are minimally angulated or bayonet opposed. The children will have to sleep in an upright position for several weeks until the fracture is healed enough to be converted to splint immobilization. These casts are simple long-arm casts that do not require intimate molding; the weight of the cast will provide gradual distraction that aligns the fracture. Common pitfalls include a patient who cannot sleep upright and placing the neck collar attachment on the forearm too close to the elbow which could increase anterior angulation or placing the attachment too close to the wrist; which could lead to posterior angulation. 

Short Leg Cast Application

Short leg casts are applied with goals of fully immobilizing the lower leg and keeping the ankle at 90 degrees while avoiding complications such as pressure sores. After applying proximal and distal stockinet the limb is wrapped with cotton padding and the ankle is held at 90 degrees. A potential pitfall is as the casting material is placed the ankle drifts into equinus, then as ankle flexion is restored to 90 degrees, casting material bunches up at the anterior ankle which can cause soft tissue damage over time as well as neurovascular constriction. To avoid excessive plaster of Paris cast material over the anterior ankle, a posterior splint of 5 layers thick is measured, and applied (Fig. 4-39) and then overwrapped with plaster rolls (Fig. 4-40). The ankle can be held at 90 degrees by the surgeon's torso and the plaster is carefully molded around the malleoli and the pretibial crest (Fig. 4-7). The cast should be hard and well cured; bivalving a wet cast will weaken it and the foot can drift into equinus. The cooled cast can be supported on a pillow with the ankle hanging free (Fig. 4-8). Once hardened the cast can be univalved and spread anteriorly if needed to accommodate swelling; if significant swelling is expected then the cast can be bivalved and spread with release of the cotton padding. Using fiberglass for short leg casts generally results in a lighter and stronger cast, but if fiberglass is improperly applied too tightly it can cause compartment syndrome. 
Figure 4-39
A 5 thickness posterior slab has been dipped and applied to the posterior foot and leg at the beginning of a short leg cast.
 
Cuts have been made at the ankle to allow good overlap without bunching. This posterior splint brings thickness and strength to the posterior part and prevents anterior bunching of plaster over the ankle. (Property of UW Pediatric Orthopaedics.)
Cuts have been made at the ankle to allow good overlap without bunching. This posterior splint brings thickness and strength to the posterior part and prevents anterior bunching of plaster over the ankle. (Property of UW Pediatric Orthopaedics.)
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Figure 4-39
A 5 thickness posterior slab has been dipped and applied to the posterior foot and leg at the beginning of a short leg cast.
Cuts have been made at the ankle to allow good overlap without bunching. This posterior splint brings thickness and strength to the posterior part and prevents anterior bunching of plaster over the ankle. (Property of UW Pediatric Orthopaedics.)
Cuts have been made at the ankle to allow good overlap without bunching. This posterior splint brings thickness and strength to the posterior part and prevents anterior bunching of plaster over the ankle. (Property of UW Pediatric Orthopaedics.)
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Figure 4-40
(Property of UW Pediatric Orthopaedics.)
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Figure 4-40
Plaster is overlapped by half and rolled up the leg over the splint.
(Property of UW Pediatric Orthopaedics.)
(Property of UW Pediatric Orthopaedics.)
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Long Leg Cast Application

Long leg cast application incorporates all of the techniques above; once the short-leg portion has hardened the upper thigh is wrapped with padding and the knee (held in the chosen degree of flexion) and thigh is overwrapped with cast material. Care is needed to make sure the posterior trimline of the short-leg cast is not too high and which could be compressing in the popliteal fossa. The anterior knee portion can be reinforced with a splint and thus further decreasing the cast load in the popliteal fossa. Finally a medial and lateral supracondylar mold (similar to that in long-arm cast) can be used to support the weight of the cast and prevent distal migration. Plaster long leg casts can be heavy, as such we will use an all fiberglass cast or consider a composite cast whereby the short-leg portion is molded with plaster of Paris and then when hardened the proximal portion is placed with fiberglass. 

Short Leg Splint Application

Posterior short leg splints are commonly used to immobilize the foot and ankle prior to definitive operative or nonoperative treatment and additionally to support the limb in the immediate postoperative period. These splints can accommodate significant swelling following trauma or surgery. Supplemental stirrup application may be needed in larger patients whose foot position cannot be controlled with a single posterior slab. In these cases, similar application methods and principles are used as seen in the upper extremity sugar-tong splint application. 
Fundamental application includes holding the foot and ankle in 90 degrees of flexion while the limb is wrapped with four to six layers of cotton padding from the toes to the knee. A posterior slab of plaster is selected and should be wide enough to provide a medial and lateral trimline of an inch. It should be 10 layers thick; and measured similarly to that seen in short leg cast application described above. If needed a U-stirrup of plaster five layers thick is measured and is usually 1 to 2 inches narrower than the posterior plaster slab; this allows overlap of the two pieces of plaster without completely covering the anterior foot, ankle, and leg. Both the stirrup and the posterior slab are dipped in water and the proximal and distal trimlines are padded with three to four more layers of cast padding. The slab is applied posteriorly; any redundant material at the level of the heel can be cut away before the U-stirrup is applied with some overlap of the stirrup and the slab. The plaster is held in place with one layer of cast padding. An elastic bandage is applied tightly until the plaster is hard, and then removed to prevent constriction. This last layer of cast padding allows for easy removal of the final layer of loosely applied elastic bandage or self-adherent elastic tape. 
Variances to this method are similar to sugar-tong splint application described above. For instance, some practitioners prefer to layer the wet plaster splint with 5 thicknesses of padding and apply the padded splint directly to the limb. This has advantages in minimizing circumferential wrapping of the limb with cotton; yet great care is needed to prevent inadvertent bunching or slipping of the padding. 

Spica Cast Application

Spica casts can be applied from infants to adolescents and the location of application can vary according to age and clinical problem. For instance, infants and most children with painful injuries will require sedation and application in the supine position on a spica table. In contrast, a single leg spica cast can be used as an adjunct to internal fixation for femur fracture in large children or adolescents. These latter casts can be applied in a supine or even a standing position with a compliant and comfortable patient. Because of the size of the casts, most spica casts are constructed with synthetic cast material; plaster of Paris still has utility in small infants where a more intimate mold is used and where it's hard to conform fiberglass rolls. 
Spica cast application in children is performed on a well-padded spica table which should be firmly attached to the OR bed or cart; one person should be responsible for managing the torso and making sure the child does not fall off the table; one to two assistants will support the legs while the anesthesia team manages the head and airway—this leaves the last of a four- to five-person team to apply the cast. 
Before placing the child on the spica table a waterproof pantaloon or stockinet is applied to the torso and legs in some centers. Place a 2- to 4-in thick towel or other pad on the stomach and under the liner or stockinette, that will be removed when the cast is dry to have room for food and respiration. Note that if the patient starts to desaturate during spica cast application pulling out the abdomen padding frequently resolves this. The child is lifted onto the table and 3 to 6 thicknesses of padding are applied, with more at bony prominences such as over the patella and heels. It is also wise to completely cover the perineum with padding and high over the thorax; it is extremely hard to add padding once the cast material is applied (Fig. 4-41). After padding is appropriately applied, the thorax is wrapped with synthetic cast material (Fig. 4-9) and extended down over the uninjured thigh; care is needed to cover the “intern's triangle,” this is the posterior area of the cast at the junction of the thigh, buttock, and thorax. Once the uninjured leg portion is hardened the injured leg is casted from proximal to distal. We recommend casting from the thorax, over the hip and to the distal thigh then extending over the knee and onto the distal leg as soon as the hip and thigh portion is firm; once the knee and leg portion is hardened then extend it down to include the foot and ankle. Care must be taken not to apply a short leg cast first, and use it to apply traction across the femur as this is associated with soft tissue problems and compartment syndrome. In general we include the foot in neuromuscular patients who are prone to develop an equinus contracture and whose distal tibia is osteoporotic and prone to fracture at the level of the distal trimline. The risk of including the foot in a spica cast is soft tissue problems over the dorsal ankle. Once the final cast is hardened the perineal region is trimmed out and patient is removed from the spica table. The abdominal pad is removed and in some children a hole can be cut for further room (Fig. 4-42). Next appropriate radiographs are obtained and the trimlines are padded from rolling back the under padding and lining and incorporated with trim fiberglass. The decision to apply a bar from leg to leg is made based on the structural integrity of the cast. Usually this is not needed in small children and infants. Should a bar be needed then it is wise to wait until the cast is fully cured and the chance of a pressure sore is decreased. Nontoilet-trained infants and children need to have an absorbent pad (small diaper, ABD pad, or sanitary napkin) placed in the perineal region and then a diaper is placed over this (Fig. 4-43). Simply placing a diaper over the cast will not absorb the waste material, as the diaper will not be in contact before it tracks under the cast. 
Figure 4-41
This 5-year-old child with a femur fracture is supported with three to four assistants as cotton padding is applied to the patient's body which is covered with a waterproof liner over a stack of towels placed as a spacer for his belly.
(Property of UW Pediatric Orthopaedics.)
(Property of UW Pediatric Orthopaedics.)
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Figure 4-42
The abdominal pillow is removed after trimming away the perineal region.
Flynn-ch004-image042.png
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Figure 4-43
When finished the spica edges are well padded and incorporated into the cast.
 
A small diaper is placed into the perineal region and then another diaper will be placed over this to hold it in place. (Property of UW Pediatric Orthopaedics.)
A small diaper is placed into the perineal region and then another diaper will be placed over this to hold it in place. (Property of UW Pediatric Orthopaedics.)
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Figure 4-43
When finished the spica edges are well padded and incorporated into the cast.
A small diaper is placed into the perineal region and then another diaper will be placed over this to hold it in place. (Property of UW Pediatric Orthopaedics.)
A small diaper is placed into the perineal region and then another diaper will be placed over this to hold it in place. (Property of UW Pediatric Orthopaedics.)
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For length-stable diaphyseal femoral shaft fractures, many centers are now moving toward a single leg spica cast, which does not include the contralateral thigh and positions the hip and knee in less flexion and give the child the opportunity to ambulate with a walker or crutches. 

Bone Remodeling

Fracture management in children affords the unique opportunity to correct residual deformity with remodeling as growth occurs. The mechanism whereby bone remodeling occurs is discussed in the chapter on Bone Biology, but includes asymmetric growth of the physis in angular deformity resulting in overgrowth of the physis on the concave side of the deformity.85 Seventy-five percent of remodeling occurs at the level of the physis, and remodeling at the level of the fracture also occurs through resorption along the convex side of the deformity with ossification along the concave side.100 Angular deformities, translational deformities, and apposition undergo a relatively predictable path of remodeling that allows for acceptance of certain amounts of malalignment rather than needing to pursue surgical correction to restore anatomic alignment prior to fracture healing.41 One notable exception is that rotational deformities may not remodel well and anatomic relationship within the axial plane should occur from the outset of fracture management.22 
Deformities closer to rapidly growing physes retain greater remodeling potential (proximal humerus remodels well, whereas distal humerus remodels little, if at all), as do angular deformities that occur within the plane of motion of the closest joint (e.g., sagittal plane deformity corrects better than coronal plane deformity at a flexion–extension joint, such as the wrist or finger). Much of the remodeling likely takes place in the first year after fracture; a rate as high as 2.5 degrees per month for metaphyseal radial fractures, with a rate of 1.5 degrees per month for diaphyseal fractures.79 Newborns, as expected, have the greatest ability for remodeling because 100% of bone mineral content turns over in the first year of life, resulting in remodeling of even dramatic deformity53 (Fig. 4-44). As a child approaches skeletal maturity the ability to remodel decreases—a child nearing skeletal maturity has minimal ability for remodeling so fracture alignment should be near-anatomic. As a result, acceptable, or allowable, deformity differs across various age ranges and anatomic locations of fractures. In general, 15 degrees of angulation is acceptable for fractures at nearly any location in a prepubertal child. Greater degrees of deformity may correct in younger children; although healing with malunion is not desired, it is likely more prudent, and cost-effective, to allow ample opportunity to remodel before undertaking surgical correction of deformity.28 
Figure 4-44
 
A: Alignment at 1 week in a newborn with a fracture sustained at birth. B: After 6 months significant remodeling has occurred, and no functional deficits are noted clinically. (Property of UW Pediatric Orthopaedics.)
A: Alignment at 1 week in a newborn with a fracture sustained at birth. B: After 6 months significant remodeling has occurred, and no functional deficits are noted clinically. (Property of UW Pediatric Orthopaedics.)
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Figure 4-44
A: Alignment at 1 week in a newborn with a fracture sustained at birth. B: After 6 months significant remodeling has occurred, and no functional deficits are noted clinically. (Property of UW Pediatric Orthopaedics.)
A: Alignment at 1 week in a newborn with a fracture sustained at birth. B: After 6 months significant remodeling has occurred, and no functional deficits are noted clinically. (Property of UW Pediatric Orthopaedics.)
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One of the most extreme examples of the power of growth in the skeletally immature child is the ability of femur fractures, and occasionally tibia fractures, to “overgrow.”67,87 This may result in limb length discrepancy when the fracture heals at length, but provides opportunity for equalization of limb discrepancy when the fracture heals in a foreshortened position (Fig. 4-45). Overgrowth following fracture may occur through increased activity at the physes of the fractured, and possibly adjacent, bone(s).32 
Figure 4-45
 
A: Femoral diaphyseal fracture that healed in 2 cm of shortening. B: After 1 year, femoral length has been almost fully restored through regrowth. (Property of UW Pediatric Orthopaedics.)
A: Femoral diaphyseal fracture that healed in 2 cm of shortening. B: After 1 year, femoral length has been almost fully restored through regrowth. (Property of UW Pediatric Orthopaedics.)
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Figure 4-45
A: Femoral diaphyseal fracture that healed in 2 cm of shortening. B: After 1 year, femoral length has been almost fully restored through regrowth. (Property of UW Pediatric Orthopaedics.)
A: Femoral diaphyseal fracture that healed in 2 cm of shortening. B: After 1 year, femoral length has been almost fully restored through regrowth. (Property of UW Pediatric Orthopaedics.)
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Top 15 Fractures to Avoid Missing, Underappreciating, or Undertreating

  1.  
    A 15-year-old hockey player is tripped and slides into the boards. He arises with the complaint of right-sided chest pain and mild shortness of breath. Tenderness is noted at the right sternoclavicular joint with minimal deformity. X-rays at urgent care were read as normal (Fig. 4-46A). He was experiencing some difficulty swallowing and slight shortness of breath, both of which improved over the next 3 weeks. After following-up in clinic, the correct diagnosis was suspected and a computed tomography (CT) obtained (Fig. 4-46B, C).
     
    Posteriorly displaced sternoclavicular fractures, as with dislocations, frequently result in restriction of cardiorespiratory function, occasionally nerve injury and, rarely, even death. Diagnosis by plain radiographs is difficult because of obscuration by the ribs on standard clavicle views and lack of a good orthogonal image. In the setting of traumatic onset of sternoclavicular pain, clinical suspicion should lead CT, the imaging modality of choice.96
  2.  
    A 4-year-old girl presents with right elbow pain after experiencing an injury from landing on the mat when jumping on a trampoline with her 13-year-old brother. AP and lateral radiographs demonstrated a nondisplaced lateral condyle fracture. After 4 weeks of casting the patient was released from care. Six years later she returns with clinical and radiographic deformities (Fig. 4-47).
     
    Stability of lateral condyle fractures may be difficult to discern on initial radiographs. Lateral condyle fractures with extension to the joint have a high propensity for displacement and nonunion. Additional views such as the internal oblique view, and close monitoring, are necessary to identify displacement and need for surgical fixation.90
  3.  
    A 10-year-old female dislocated her elbow and it popped back in place by her physician father. She has swelling throughout the elbow, bruising and tenderness medially to palpation. Radiographs reveal an ossific density overlying the distal humerus (Fig. 4-48).
     
    Medial epicondyle fractures occur in 50% of elbow dislocations or may occur as isolated injuries.36 Dislocations create an opportunity for the avulsed medial epicondyle to become entrapped in the joint. Contralateral films or CT scan will help with identification.
  4.  
    A 2-year-old boy has an undefined elbow injury after a fall from his bed; radiographs were considered questionable for a distal humerus fracture, and an MRI was performed by his treating physician. This was suggestive of a distal humerus fracture, he was taken to the OR where an arthrogram demonstrated the injury and he underwent closed reduction and pinning (Fig. 4-49AC).
     
    The distal humerus is the most common location for a transphyseal fracture. Transphyseal fractures may occur in the presence of a difficult extraction of a neonate or nonaccidental trauma, rarely occurring via other mechanisms. Infants commonly present with pseudoparalysis of the extremity, fussiness, and often a swollen joint. Radiographs appear normal as the fracture is an avulsion of the nonossified epiphysis through the physis with a minimal or no metaphyseal fragment. Neonates may do well54 but at any other age, missed fractures have a high rate of avascular necrosis (AVN) of the medial condyle and subsequent cubitus varus.74
  5.  
    A 5-year-old male presents with his parents with concerns regarding elbow deformity after a fracture at 2 years old. He has a gunstock deformity to his left elbow, which also hyperextends. Review of old radiographs, and new imaging, reveals a supracondylar humerus fracture treated conservatively that healed in extension and varus (Fig. 4-50).
     
    Type 2 supracondylar humerus fractures may rarely be amenable to nonsurgical treatment. Before doing so, alignment in the coronal and sagittal planes should be carefully assessed using contralateral films and measurement of Baumann angle to make sure the fracture is not in varus/valgus malalignment and/or hyperextension that requires reduction and/or surgical intervention.102
  6.  
    A 4-year-old female presents with arm deformity after falling off her bike. Neurovascular examination is normal. Radiographs reveal a diaphyseal ulna fracture. She is casted and goes on to good healing at 4 weeks. Six months later she returns with difficulty pronating and supinating her forearm; radiographs reveal malalignment of the radiocapitellar joint (Fig. 4-51).
     
    Numerous variations exist, but Monteggia fractures and their equivalents involve an ulnar fracture with associated radial head dislocation. Focus on the forearm frequently results in missing the radiocapitellar component either through ordering only forearm radiographs, excluding orthogonal visualization of the elbow, or a lack of proper interpretation of elbow radiographs. Missed or delayed diagnoses require surgical correction often with an increased risk of complications.82
  7.  
    A 12-year-old male presents with wrist pain and deformity after falling off a skateboard when going down a hill. He undergoes reduction of his distal radius metaphyseal fracture and goes on to full healing. Three years later he returns with wrist pain. Radiographs reveal ulnar shortening and growth arrest (Fig. 4-52).
     
    Nearly 50% of distal ulnar physeal fractures undergo growth arrest.11 Nondisplaced ulnar physeal fractures may not be appreciated on initial imaging but will demonstrate evidence of healing 2 to 4 weeks after injury. When identified, follow-up imaging 6 to 9 months after injury helps identify growth arrest before it becomes clinically significant.
  8.  
    A 10-year-old male presents with pain and swelling about his 2nd finger after throwing a pass and getting his finger stuck in another player's face mask. Radiographs reveal a fracture through the distal phalangeal neck. He is reduced and splinted 3 months later he returns with no pain, but slightly limited flexion. Radiographs reveal adequate healing (Fig. 4-53).
     
    Phalangeal neck fractures lead to limitation in motion because of fracture extension of the articular surface which leads to a block to flexion into the subcondylar fossa.21 Remodeling is minimal, so radiographs require critical evaluation to determine need for reduction and fixation.
  9.  
    A 6-year-old male presents with right anterior distal thigh pain after a weekend at a local water park. No injury was noted. Radiographs of his knee are normal. He is told to follow up with orthopedics. One week later he presents with slightly improved discomfort, but persistent limp. Examination is remarkable for limited hip abduction and internal rotation. Radiographs of the pelvis reveal sclerosis of the proximal femur with confirmation of a suspected fracture on MRI (Fig. 4-54).
     
    Femoral neck fractures have catastrophic sequelae because of AVN.24 Early recognition and intervention is necessary to prevent further displacement and AVN.
  10.  
    A 15-year-old male presents with acute onset of hip pain after being tackled while playing football and having his left thigh forcefully flexed up to his chest when landed on by another player. Radiographs demonstrate a left hip dislocation (Fig. 4-55).
     
    AP radiographs may be difficult to interpret, but lateral films usually confirm the dislocation. Prompt diagnosis and reduction under deep sedation or general anesthesia is critical to decrease the risk of subsequent AVN. Fluoroscopic imaging is used during reduction to detect concomitant physeal fracture during the reduction. Forced reduction (as would be encountered with poor sedation) and without radiographic monitoring could displace the femoral head through an unrecognized and injured physis in a skeletally immature child or adolescent.49
  11.  
    A 14-year-old female presents with swelling of her knee after coming down from a rebound in a basketball game. She is swollen throughout her knee but more so over her tibial tubercle. Radiographs identify a displaced avulsion fracture involving the anterior epiphysis and tubercle (Fig. 4-56). She is placed into a splint in extension and told to follow up with the orthopedist the next day. She returns to the emergency department 6 hours later with increased pain, paresthesias, and inability to move her foot or toes.
     
    Tibial tubercle fractures result in disruption of the extensor mechanism of the knee. Displaced fractures require surgical fixation and carry a risk of development of compartment syndrome.70 As a result, patients should be admitted for observation.
  12.  
    A 12-year-old male presents to his primary physician with knee pain after falling while riding his bicycle. On examination he has an effusion, no areas of focal tenderness, and a negative Lachman maneuver. He is diagnosed with a sprain and placed into a knee immobilizer for comfort. He comes to clinic 4 weeks later because of persistent pain and swelling. Radiographs demonstrate a fracture involving the tibial eminence (Fig. 4-57).
     
    As opposed to adults who tear their anterior cruciate ligament (ACL), skeletally immature children who experience the same mechanism of trauma can avulse the tibial eminence. Any child with knee swelling following hyperextension trauma should undergo careful radiographic study. Radiographs should be closely scrutinized for displacement of the tibial spine to identify lesions that benefit from surgical intervention,1 or immobilization. Despite the fact that the attachment of the ACL is disrupted, the Lachman test may be negative.
  13.  
    A 3-year-old male presents with pain in his leg after being fallen on by another child in a bounce house. Radiographs reveal a transverse fracture of the proximal tibial metaphysis that undergoes reduction and fixation in anatomic alignment. Twelve months later he returns with his parents for a “crooked leg.” Radiographs reveal valgus angulation of the proximal tibia (Fig. 4-58).
     
    Fractures of the proximal tibia can grow into valgus at the proximal growth plate over time. Progressive valgus alignment can occur after surgical or nonsurgical treatment. Alignment is likely to correct with continued bone growth95,103 without intervention so observation for at least a year is indicated in most cases. However, surgical correction via hemiepiphysiodesis is occasionally needed. Awareness on the part of the physician and parents helps alleviate anxiety or need to pursue surgical correction when deformity occurs.
  14.  
    A 13-year-old female presents with ankle pain and swelling after tripping in the backyard when running after some friends. She says that she stepped in a depression in the ground while running down hill, lost her balance and fell. Radiographs are obtained demonstrating a Tillaux fracture of the distal tibia (Fig. 4-59).
     
    Transitional fractures of the distal tibial physis include the Tillaux fracture and the triplane fracture (Fig. 4-60), which occur as the physis begins to close. Vertical components in the sagittal plane may be difficult to identify. Plain radiographs often underestimate the true amount of fracture displacement, which is best seen on CT.31,50
  15.  
    A 2-year-old female presents following an injury to her fourth finger after being slammed in a car door. The nail is avulsed proximally with bleeding from the nail bed. Radiographs reveal a fracture of the distal phalanx with slight volar angulation (Fig. 4-61).
     
    The eponymous Seymour fracture of the distal phalanx may occur in the hand or the foot and include a paraphyseal or physeal fracture of the distal phalanx with avulsion of the nail bed and often entrapment of the germinal matrix or extensor sheath within the fracture. Risk of infection and malunion occurs if the soft tissue component is not repaired.30
Figure 4-46
 
A: AP view of both clavicles does not demonstrate any obvious abnormality. B: Computed tomography 4 weeks later demonstrates posteriorly displaced proximal clavicle fracture, more fully appreciated on three-dimensional reconstruction (C). (Used with permission from the Children's Orthopaedic Center, Los Angeles.)
A: AP view of both clavicles does not demonstrate any obvious abnormality. B: Computed tomography 4 weeks later demonstrates posteriorly displaced proximal clavicle fracture, more fully appreciated on three-dimensional reconstruction (C). (Used with permission from the Children's Orthopaedic Center, Los Angeles.)
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Figure 4-46
A: AP view of both clavicles does not demonstrate any obvious abnormality. B: Computed tomography 4 weeks later demonstrates posteriorly displaced proximal clavicle fracture, more fully appreciated on three-dimensional reconstruction (C). (Used with permission from the Children's Orthopaedic Center, Los Angeles.)
A: AP view of both clavicles does not demonstrate any obvious abnormality. B: Computed tomography 4 weeks later demonstrates posteriorly displaced proximal clavicle fracture, more fully appreciated on three-dimensional reconstruction (C). (Used with permission from the Children's Orthopaedic Center, Los Angeles.)
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Figure 4-47
 
A: Lateral and (B) AP views at presentation demonstrating a minimally displaced lateral condyle fracture in a 4-year-old. C: AP radiograph in a 10-year-old with a prior lateral condyle fracture, now with nonunion and valgus deformity. (Property of UW Pediatric Orthopaedics.)
A: Lateral and (B) AP views at presentation demonstrating a minimally displaced lateral condyle fracture in a 4-year-old. C: AP radiograph in a 10-year-old with a prior lateral condyle fracture, now with nonunion and valgus deformity. (Property of UW Pediatric Orthopaedics.)
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Figure 4-47
A: Lateral and (B) AP views at presentation demonstrating a minimally displaced lateral condyle fracture in a 4-year-old. C: AP radiograph in a 10-year-old with a prior lateral condyle fracture, now with nonunion and valgus deformity. (Property of UW Pediatric Orthopaedics.)
A: Lateral and (B) AP views at presentation demonstrating a minimally displaced lateral condyle fracture in a 4-year-old. C: AP radiograph in a 10-year-old with a prior lateral condyle fracture, now with nonunion and valgus deformity. (Property of UW Pediatric Orthopaedics.)
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Figure 4-48
 
A: AP and (B) lateral of the unaffected right elbow with the medial epicondyle in anatomic position (arrows). The medial epicondyle is seen to be entrapped in the joint on both (C) AP and (D) lateral views (arrowheads). (Property of UW Pediatric Orthopaedics.)
A: AP and (B) lateral of the unaffected right elbow with the medial epicondyle in anatomic position (arrows). The medial epicondyle is seen to be entrapped in the joint on both (C) AP and (D) lateral views (arrowheads). (Property of UW Pediatric Orthopaedics.)
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Figure 4-48
A: AP and (B) lateral of the unaffected right elbow with the medial epicondyle in anatomic position (arrows). The medial epicondyle is seen to be entrapped in the joint on both (C) AP and (D) lateral views (arrowheads). (Property of UW Pediatric Orthopaedics.)
A: AP and (B) lateral of the unaffected right elbow with the medial epicondyle in anatomic position (arrows). The medial epicondyle is seen to be entrapped in the joint on both (C) AP and (D) lateral views (arrowheads). (Property of UW Pediatric Orthopaedics.)
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Figure 4-49
 
A: Less than optimal plain radiograph of an anxious crying 2-year-old is nondiagnostic for injury. B: Because of difficulty obtaining standard films and contralateral comparison films an MRI was obtained which demonstrates likely transphyseal fracture. C: Arthrogram before pinning demonstrates extension of the distal fragment. (Property of UW Pediatric Orthopaedics.)
A: Less than optimal plain radiograph of an anxious crying 2-year-old is nondiagnostic for injury. B: Because of difficulty obtaining standard films and contralateral comparison films an MRI was obtained which demonstrates likely transphyseal fracture. C: Arthrogram before pinning demonstrates extension of the distal fragment. (Property of UW Pediatric Orthopaedics.)
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Figure 4-49
A: Less than optimal plain radiograph of an anxious crying 2-year-old is nondiagnostic for injury. B: Because of difficulty obtaining standard films and contralateral comparison films an MRI was obtained which demonstrates likely transphyseal fracture. C: Arthrogram before pinning demonstrates extension of the distal fragment. (Property of UW Pediatric Orthopaedics.)
A: Less than optimal plain radiograph of an anxious crying 2-year-old is nondiagnostic for injury. B: Because of difficulty obtaining standard films and contralateral comparison films an MRI was obtained which demonstrates likely transphyseal fracture. C: Arthrogram before pinning demonstrates extension of the distal fragment. (Property of UW Pediatric Orthopaedics.)
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Figure 4-50
 
A: AP and (B) lateral views of the elbow demonstrating a type 2 supracondylar humerus fracture at presentation. C and D: Showing healing in varus and hyperextension. E and F: Imaging 3 years later shows persistent varus and extension without evidence of remodeling. Clinically, the patient has a gunstock deformity (G) and hyperextension (H). (Property of UW Pediatric Orthopaedics.)
A: AP and (B) lateral views of the elbow demonstrating a type 2 supracondylar humerus fracture at presentation. C and D: Showing healing in varus and hyperextension. E and F: Imaging 3 years later shows persistent varus and extension without evidence of remodeling. Clinically, the patient has a gunstock deformity (G) and hyperextension (H). (Property of UW Pediatric Orthopaedics.)
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Figure 4-50
A: AP and (B) lateral views of the elbow demonstrating a type 2 supracondylar humerus fracture at presentation. C and D: Showing healing in varus and hyperextension. E and F: Imaging 3 years later shows persistent varus and extension without evidence of remodeling. Clinically, the patient has a gunstock deformity (G) and hyperextension (H). (Property of UW Pediatric Orthopaedics.)
A: AP and (B) lateral views of the elbow demonstrating a type 2 supracondylar humerus fracture at presentation. C and D: Showing healing in varus and hyperextension. E and F: Imaging 3 years later shows persistent varus and extension without evidence of remodeling. Clinically, the patient has a gunstock deformity (G) and hyperextension (H). (Property of UW Pediatric Orthopaedics.)
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Figure 4-51
 
A: AP and (B) lateral views of the forearm demonstrating ulnar diaphyseal fracture. Radial head dislocation can be appreciated on these views. C and D: Follow-up imaging did not include the elbow. E: Radial head dislocation is appreciated 6 months later. (Property of UW Pediatric Orthopaedics.)
A: AP and (B) lateral views of the forearm demonstrating ulnar diaphyseal fracture. Radial head dislocation can be appreciated on these views. C and D: Follow-up imaging did not include the elbow. E: Radial head dislocation is appreciated 6 months later. (Property of UW Pediatric Orthopaedics.)
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Figure 4-51
A: AP and (B) lateral views of the forearm demonstrating ulnar diaphyseal fracture. Radial head dislocation can be appreciated on these views. C and D: Follow-up imaging did not include the elbow. E: Radial head dislocation is appreciated 6 months later. (Property of UW Pediatric Orthopaedics.)
A: AP and (B) lateral views of the forearm demonstrating ulnar diaphyseal fracture. Radial head dislocation can be appreciated on these views. C and D: Follow-up imaging did not include the elbow. E: Radial head dislocation is appreciated 6 months later. (Property of UW Pediatric Orthopaedics.)
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Figure 4-52
 
A and B: Distal radius and ulna injury and at follow-up a growth arrest of the distal ulna presenting 3 years after initial injury. (Property of UW Pediatric Orthopaedics.)
A and B: Distal radius and ulna injury and at follow-up a growth arrest of the distal ulna presenting 3 years after initial injury. (Property of UW Pediatric Orthopaedics.)
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Figure 4-52
A and B: Distal radius and ulna injury and at follow-up a growth arrest of the distal ulna presenting 3 years after initial injury. (Property of UW Pediatric Orthopaedics.)
A and B: Distal radius and ulna injury and at follow-up a growth arrest of the distal ulna presenting 3 years after initial injury. (Property of UW Pediatric Orthopaedics.)
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Figure 4-53
 
A: AP and (B) lateral views of index finger at presentation demonstrating phalangeal neck fracture. C: AP and (D) lateral views 3 months later show good healing, but the patient still has slight limitation of flexion. (Property of UW Pediatric Orthopaedics.)
A: AP and (B) lateral views of index finger at presentation demonstrating phalangeal neck fracture. C: AP and (D) lateral views 3 months later show good healing, but the patient still has slight limitation of flexion. (Property of UW Pediatric Orthopaedics.)
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Figure 4-53
A: AP and (B) lateral views of index finger at presentation demonstrating phalangeal neck fracture. C: AP and (D) lateral views 3 months later show good healing, but the patient still has slight limitation of flexion. (Property of UW Pediatric Orthopaedics.)
A: AP and (B) lateral views of index finger at presentation demonstrating phalangeal neck fracture. C: AP and (D) lateral views 3 months later show good healing, but the patient still has slight limitation of flexion. (Property of UW Pediatric Orthopaedics.)
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Figure 4-54
 
A: AP pelvis including both hips 1 week after onset of right knee pain demonstrating sclerosis at the inferior portion of the right femoral neck. B and C: MRI demonstrates a propagating fracture prompting (D) surgical fixation to prevent complete fracture and displacement. (Property of UW Pediatric Orthopaedics.)
A: AP pelvis including both hips 1 week after onset of right knee pain demonstrating sclerosis at the inferior portion of the right femoral neck. B and C: MRI demonstrates a propagating fracture prompting (D) surgical fixation to prevent complete fracture and displacement. (Property of UW Pediatric Orthopaedics.)
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Figure 4-54
A: AP pelvis including both hips 1 week after onset of right knee pain demonstrating sclerosis at the inferior portion of the right femoral neck. B and C: MRI demonstrates a propagating fracture prompting (D) surgical fixation to prevent complete fracture and displacement. (Property of UW Pediatric Orthopaedics.)
A: AP pelvis including both hips 1 week after onset of right knee pain demonstrating sclerosis at the inferior portion of the right femoral neck. B and C: MRI demonstrates a propagating fracture prompting (D) surgical fixation to prevent complete fracture and displacement. (Property of UW Pediatric Orthopaedics.)
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Figure 4-55
 
A: AP pelvis of a patient with a traumatic left hip dislocation, the AP image does not clearly define the displacement posteriorly. B: Cross-table lateral views better demonstrate the posterior positioning of the femoral head. (Property of UW Pediatric Orthopaedics.)
A: AP pelvis of a patient with a traumatic left hip dislocation, the AP image does not clearly define the displacement posteriorly. B: Cross-table lateral views better demonstrate the posterior positioning of the femoral head. (Property of UW Pediatric Orthopaedics.)
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Figure 4-55
A: AP pelvis of a patient with a traumatic left hip dislocation, the AP image does not clearly define the displacement posteriorly. B: Cross-table lateral views better demonstrate the posterior positioning of the femoral head. (Property of UW Pediatric Orthopaedics.)
A: AP pelvis of a patient with a traumatic left hip dislocation, the AP image does not clearly define the displacement posteriorly. B: Cross-table lateral views better demonstrate the posterior positioning of the femoral head. (Property of UW Pediatric Orthopaedics.)
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(Property of UW Pediatric Orthopaedics.)
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Figure 4-56
Lateral view of the knee demonstrating a type III tibial tubercle fracture.
(Property of UW Pediatric Orthopaedics.)
(Property of UW Pediatric Orthopaedics.)
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Figure 4-57
AP views of both knees demonstrating lucency through base of the tibial eminence of the left knee as well as a small avulsion off the lateral tibial spine.
(Property of UW Pediatric Orthopaedics.)
(Property of UW Pediatric Orthopaedics.)
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Figure 4-58
 
A: AP and (B) lateral knee x-rays demonstrating a transverse fracture through the proximal tibia that underwent surgical reduction and fixation (C). Clinically, the patient developed a progressive valgus deformity of the left leg (D). E: Radiographs confirm a valgus deformity through the proximal tibia. (Property of UW Pediatric Orthopaedics.)
A: AP and (B) lateral knee x-rays demonstrating a transverse fracture through the proximal tibia that underwent surgical reduction and fixation (C). Clinically, the patient developed a progressive valgus deformity of the left leg (D). E: Radiographs confirm a valgus deformity through the proximal tibia. (Property of UW Pediatric Orthopaedics.)
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Figure 4-58
A: AP and (B) lateral knee x-rays demonstrating a transverse fracture through the proximal tibia that underwent surgical reduction and fixation (C). Clinically, the patient developed a progressive valgus deformity of the left leg (D). E: Radiographs confirm a valgus deformity through the proximal tibia. (Property of UW Pediatric Orthopaedics.)
A: AP and (B) lateral knee x-rays demonstrating a transverse fracture through the proximal tibia that underwent surgical reduction and fixation (C). Clinically, the patient developed a progressive valgus deformity of the left leg (D). E: Radiographs confirm a valgus deformity through the proximal tibia. (Property of UW Pediatric Orthopaedics.)
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Figure 4-59
 
A: AP view demonstrating a Tillaux fracture with vertical, sagittal epiphyseal and horizontal, axial physeal components. B: Computed tomography is useful for defining transitional fracture pattern. In Triplane fractures there is a sagittal split (similar to that in Tillaux fractures) with a transverse fracture through the growth plate and an ascending coronal split up the metaphysis. (Property of UW Pediatric Orthopaedics.)
A: AP view demonstrating a Tillaux fracture with vertical, sagittal epiphyseal and horizontal, axial physeal components. B: Computed tomography is useful for defining transitional fracture pattern. In Triplane fractures there is a sagittal split (similar to that in Tillaux fractures) with a transverse fracture through the growth plate and an ascending coronal split up the metaphysis. (Property of UW Pediatric Orthopaedics.)
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Figure 4-59
A: AP view demonstrating a Tillaux fracture with vertical, sagittal epiphyseal and horizontal, axial physeal components. B: Computed tomography is useful for defining transitional fracture pattern. In Triplane fractures there is a sagittal split (similar to that in Tillaux fractures) with a transverse fracture through the growth plate and an ascending coronal split up the metaphysis. (Property of UW Pediatric Orthopaedics.)
A: AP view demonstrating a Tillaux fracture with vertical, sagittal epiphyseal and horizontal, axial physeal components. B: Computed tomography is useful for defining transitional fracture pattern. In Triplane fractures there is a sagittal split (similar to that in Tillaux fractures) with a transverse fracture through the growth plate and an ascending coronal split up the metaphysis. (Property of UW Pediatric Orthopaedics.)
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Figure 4-60
Computed tomography of a triplane fracture of the distal tibia which typically is involving vertical sagittal (epiphyseal), horizontal axial (physeal), and vertical coronal (metaphyseal) components.
(Property of UW Pediatric Orthopaedics.)
(Property of UW Pediatric Orthopaedics.)
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Figure 4-61
 
A: Paraphyseal fracture lucency is seen as part of a distal phalanx fracture with nail bed avulsion. B: Lateral view reveals deformity. (Property of UW Pediatric Orthopaedics.)
A: Paraphyseal fracture lucency is seen as part of a distal phalanx fracture with nail bed avulsion. B: Lateral view reveals deformity. (Property of UW Pediatric Orthopaedics.)
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Figure 4-61
A: Paraphyseal fracture lucency is seen as part of a distal phalanx fracture with nail bed avulsion. B: Lateral view reveals deformity. (Property of UW Pediatric Orthopaedics.)
A: Paraphyseal fracture lucency is seen as part of a distal phalanx fracture with nail bed avulsion. B: Lateral view reveals deformity. (Property of UW Pediatric Orthopaedics.)
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Conclusion

In this chapter we highlight the pearls and pitfalls of cast and splint application in children with pediatric orthopedic trauma. This orthopedic subspecialty is one of the few in which an injury is more likely treated with these methods than surgical treatment. A dearth of prospective studies means that much art and personal preferences remain in cast and splint application. As time moves along and there are more innovative methods to treat fractures with surgery, the role of casting will not be supplanted, there will always be a need for a technically well-done cast that helps speed recovery in pediatric trauma. In our minds the many complications result from inappropriate use of the cast or splint to obtain correction; in contrast the cast or splint should be used to maintain reduction achieved either open or closed. Tight casts and bandages are also commonly associated with compartment syndrome. Problems such as tight casts, wet casts leading to infection, foreign objects in casts, and pressure ulcers are not uncommon. It is important to educate parents that small children may not adequately communicate problems occurring under a cast. It is good for us all to remember that in the words of Chad Price, MD, “there are no hypochondriacs in a cast.” 

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