Cast Application Techniques for Common Pediatric Injuries

A Review

Karim Sabeh, MD; Amiethab Aiyer, MD; Spencer Summers, MD; William Hennrikus, MD


Curr Orthop Pract. 2020;31(3):277-287. 

In This Article

Basic Do's and Don'ts

  • Confirm that all the required materials are available before proceeding with casting.

  • Stockinettes should be 1 inch longer than the final cast length both proximally and distally. This extra material is needed to fold the stockinette before applying the last layer of cast material to ensure adequate padding.

  • Stockinette options include covering the entire surface or covering only cuffs of stocking above and below the area. Cutting the stockinette along concave skin creases avoids wrinkles, which can cause skin breakdown (Figure 2).

  • Fiberglass edges tend to be sharp and can cause skin cuts if left unpadded.

  • To form the proximal and distal ends of the cast, fold the loose end of the stockinette over the edges of the cast (Figure 3). Then, proceed with adding another layer of cast material just below the edges. That will secure the loose ends of the stockinette and avoid direct contact between the sharp cast edges and bare skin.

  • All bony prominences must be padded adequately.

  • To apply cast padding, roll distal to proximal with 50% overlap. A minimum of two layers is needed to ensure adequate padding, but no more than four layers should be used in order to avoid making the cast too thick, which limits the ability to mold the cast adequately.

  • The cast should be snugly applied for it to be effective. However, a circumferential tight cast, applied to a fresh fracture, can cause pain and discomfort as well as impede perfusion to the extremity. Splitting and spreading the cast in such situations is prudent to decreasing compartment pressures.[8] In rare situations, tight casts can lead to compartment syndrome of the extremity.[9,10]

  • Allow enough time to mold the cast if maintaining fracture reduction is warranted.

  • Use soap at the end of application to smooth and mold the cast.

  • Confirm that the fracture is appropriately reduced with biplanar radiographs once the cast has been applied.

  • Document the distal neurovascular status before and after fracture reduction and cast application.

  • Avoid excessively thick plaster, use of dip water greater than 24 degrees, and resting the cast on a pillow while it is curing. These factors can increase the risk of thermal injury to the skin.[11–13]

Figure 2.

Stockinette application. (A) Covering only cuffs of stocking above and below the area. (B) Cutting the stockinette along skin creases.

Figure 3.

(A and B) Edges of stockinette folded back before applying final layer of fiberglass.