Cast Removal

 Source

·       Guilbault R, Shore BJ. J Pediatr Soc North Am. 2025 Jul 3;12:100237.
doi: 10.1016/j.jposna.2025.100237.

 

Backgrounds

·         Cast removal is equally important as cast application in pediatric fracture care, especially in resource-limited settings where nonoperative options become mainstream.

·         As orthopedic subspecialization advances, clinical delegation requires that cast removal ability be a routine proficiency, to assure a comfortable and safe cast removal.

·         Improper techniques can pose patients at risk to burns (from saw blade heat or friction), lacerations (from over pressure).

 

Indications

·         Routine removal of cast for fracture healing or transitioning to bracing.

o   Most common indication for cast removal is completed fracture healing, determined clinically (absence of pain on fracture site palpation or weight bearing) and radiographically (callus formation and continuous bone cortices on the fracture site).

o   Pediatric fractures heal faster than those in adults due to better regenerative potential, but still influenced by site and severity.

§  Distal radius fracture may only need splint for 3 weeks without a cast, yet midshaft femoral fracture may need 4-6 weeks of spica casting.

o   Another indication is the need to transition into other forms of immobilization, where rigid casting is no longer necessary.

§  Usually following adequate yet partial healing with or without minimal tenderness, while still needing some form of protection and mobilization to maintain joint function).

§  Such as thumb spica cast of scaphoid fracture, or forearm fracture casting, transitioned into removable splint or brace.

·         Removal of improperly applied / damaged / wet / overly tight cast.

·         Assessment and management of suspected compartment syndrome, pressure sores, or other soft tissue problems beneath the cast.

o   Complications that may be indicated by pallor, increasing pain, numbness points to inadvertent increase in pressure or neurovascular compromise.

o   Pressure ulcers due to improper cast molding also necessitate early cast removal or windowing.

o   Increased risk of pressure ulcers include bony prominences such as ulnar styloid, and lateral malleolus, where inadequate padding or excessive compression may cause skin breakdown.

o   Excessive moisture trapped under the cast can cause skin maceration, leading to skin breakdown.

o   Any material lodged beneath the cast also necessitates early removal as it may irritate or injure the skin / limb.

o   Rarely complications associated with cast application such as overheating fiberglass or plaster may necessitate early cast removal.

o   Uncooperative children may attempt to pick away the padding around their fingers, in which case alternative mobilizations may be used, such as mittens cast for

 

Methods

·         Patient and Equipment Preparation:

o   Patient seated comfortably.

o   Equipments prepared and inspected for dirtiness (can damage saw blade when unaddressed):

§  Cast saw (clean, functional motors, sharp for efficiency)

§  Bandage scissors to cut underlying padding and stockinette

§  Protective gloves

§  Protective eyewears for the patient and the Cutter.

§  Vacuum or suction device to minimize dispersal of fiberglass or plaster, providing safer environment (less airborne debris and contaminants) and clearer visual for cutting, and helps dissipating saw blade heat.

§  Alcohol swabs or damp cloth to clean up debris from skin after cast removal.

§  Cast spreaders.

 

 

o   Children can be particularly sensitive to loud sounds and the appearance of the saw

§  While improperly used, the saw can cut through skin, carefully apply the saw onto your skin to demonstrate its safety.

§  Applying music or a headphone can help with the sounds.

o   Special considerations for younger children

§  Thinner skin impose higher risk of injury from cast cutting procedure.

§  Alternative include soaking fiberglass cast in water for removal instead.

§  Waterproof cast may have predetermined areas for cutting under which tapes are placed to protect the underlying skin from heat.

·         Proper saw technique

o   Perpendicular (90 degree) to the cast surface longitudinally.

o   Intermittent (in-out) contact, with frequent rests (motor off), avoiding sliding the saw through the cast (will cause heat buildup and injury) to prevent overheating and injury.

§  Cast saw burns are rare (most commonly occurring in emergency departments), with incidence of around 1 per 1000 cast removals.

§  A water or 70% isopropyl alcohol-soaked gauze or cloth can help perceive and cool down the blade heat when off.

§  A temperature increase of 20 – 40 C has been reported in a blade used for 3-5 times vs a brand new one.

§  Fiberglass can produce around additional 7 C increase on skin temperature when being cut.

§  Underlying padding, even just 2-4 layers of difference, can reduce skin temperature by 8 C.

§  Obstructed blade, such as from improper angling, will accelerate heat buildup and may damage tissues.

 

o   Expeditious cutting helps in reducing patient anxiety and risk of injury, sometimes performed by cutting partial depth, followed by full depth rather than full depth immediately.

o   Visualize the cutting path and avoid concavities (junctions between limb structures in which the cast forms indentations) if possible, because an attempt to cut the deepest cast fibers in the concave are of the cast will injure the underlying tissue.

o   Angling the saw may cause laceration to the skin despite its oscillatory nature.

·         Adequate Padding Evaluation

o   Palpate the underlying skin before full-depth cut to avoid lacerations.

o   Bracing the saw with the index finger could prevent plunging of the saw.

o   Prior padding assessment can help engage safe depth of cut.

o   When resources allow, sub-cast plastic strips can be inserted under the padding to protect the underlying skin from heat, however this does not always work, and may introduce iatrogenic skin injury when excessive force is used to place the strips.

·         Bivalving Approach

o   Circumferential cast needs to be cut with bivalve approach (two sides, avoiding bony prominences) in the safer areas of the tissue, such as volar and dorsal forearm.

·         Use of Cast Spreaders

o   Avoid using scissors or fingers to open up the cut section, to prevent inadvertent pressure increase in the tissue.

·         Final Padding Removal

o   After the hard shell is removed, remove the underlying padding with blunt-tipped scissors, ensuring no contact with the underlying skin.

·         Post-Removal Skin Exam

o   Evaluate for pressure sores, dermatitis, or residual swelling that may need further orthopedic management.