The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 94, Issue 20

Scientific Articles | October 17, 2012

Plaster: Our Orthopaedic Heritage: AAOS Exhibit Selection

Marlene DeMaio, MD (CAPT MC, USN)¹; Kathleen McHale, MD (COL MC, USA [ret])²; Martha Lenhart, MD, PhD (COL MC, USA)²; Joshua Garland, MD (LCDR MC, USN)¹; Christopher McIlvaine³; Michael Rhode, BA⁴

¹ Department of Orthopaedic Surgery, Naval Medical Center Portsmouth, 620 John Paul Jones Boulevard, Portsmouth, VA 23708
² Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814. E-mail address for K. McHale: colmchale@yahoo.com
³ Department of Exercise Science, University of South Carolina, 921 Assembly Street, Columbia, SC 29208
⁴ Office of Medical History, U.S. Navy Bureau of Medicine and Surgery, 7700 Arlington Boulevard, Suite 5113, Falls Church, VA 22042-5113

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Investigation performed at the Naval Medical Center, Portsmouth, VirginiaDisclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government. Some of the authors are military service members. This work was prepared as part of their official duties. Title 17 U.S.C. 105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person’s official duties.

J Bone Joint Surg Am, 2012 Oct 17;94(20):e152 1-8. doi: 10.2106/JBJS.L.00183

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Abstract

Background:

Plaster has been used for centuries as a stiffening agent to treat fractures and other musculoskeletal conditions that require rest, immobilization, or correction of a deformity. Despite modern metallurgy and internal stabilization, plaster casts and splints remain an important means of external stabilization. Casting is a dying art as modern internal and external fixation replace external immobilization. Proper casting technique is paramount. This manuscript outlines the history and chemistry of immobilization materials and techniques as well as the differences among them and the advantages and disadvantages of each.

Methods:

Historical references, peer-reviewed journals, textbooks, and primary sources were reviewed to provide data for this review.

Results:

The history of immobilization reveals a progressive development and refinement of materials that culminated in Mathijsen’s plaster bandage in 1851. In 1798, calcium sulfate (plaster of Paris) was introduced. By 1927, crinoline rolls dipped in plaster treated with binding agents facilitated application. Synthetic casting “tapes” (45% polyurethane resin and 55% fiberglass) were introduced in the 1970s. Splinting techniques are ancient, with development spurred by treatment of war wounds. Plaster relies on soft-tissue contact to maintain rigidity. There are well-known advantages, disadvantages, and complications of plaster management. Casting materials all create an exothermic reaction. Burns are associated with water temperatures of >24°C, more than eight layers (ply), and inadequate ventilation. The maximum water temperature must be lower with fiberglass casts. Plaster was the definitive management for most fractures for over 100 years until it was replaced by modern surgical techniques involving internal fixation in the latter part of the twentieth century.

Conclusions:

Plaster casts and splints remain an important treatment method for acute and chronic orthopaedic conditions.

Figures in this Article

Introduction

The first record of the use of plaster for stiffening bandages was by the Arabian surgeon Avicenna (Abou-Ebn-Sina) in the ninth century. Modern plaster usage dates to 1852 in Holland (by the military surgeon Antonius Mathijsen, 1805 to 1878). Before the use of internal implants, plaster casts were used as the definitive management for any condition requiring immobilization or application of a force to address a deformity¹. Fractures, infections, and congenital or developmental conditions were all treated with plaster immobilization. Open tibial fractures were treated in long-leg casts until the 1960s. Plaster splints remain useful for temporary immobilization and for the reduction of soft-tissue swelling; they may be used alone or in conjunction with internal fixation (usually flexible nails or pins). Plaster continues to be a safe, cost-effective treatment relying on soft-tissue contact to maintain rigidity.

Historical Review

The earliest known splinting of extremities involves sticks and bandages of palm fiber with linen found in prehistoric remains and in mummies (Fig. 1) and documented in the Edwin Smith surgical papyrus (approximately 3000 to 2500 BC)^2,3. Linen glued together with plaster (cartonnage) and bamboo splints tied with string were described in the manuscript by Suśruta (600 BC to AD 600)^3,4.

Fig. 1

An ancient splint from an Egyptian mummy with a fractured femur, documented in the Edwin Smith Papyrus (Reproduced from: Br Med J. 1908 Mar 28;1[2465]:732-62, copyright 1908, with permission from BMJ Publishing Group Ltd.)

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Although Hippocrates (460 to 377 BC) recognized the importance of splints and “roller bandages” for fracture care, none contained plaster. Bandages were stiffened by increasing the number of layers and by adding wax, pitch, lard, or resin^3,4.

The Romans, world-renowned for their development of concrete and art plaster frescoes, did not apply plaster to medical bandages. In AD 30, Celsus (25 BC to AD 50) recorded stiffening splints and bandages with starch. Galen (129 to 217?) described the use of bandages, including the spica type, for fractures in De Fasciis liber (Book on Bandages)^3-7.

The first recorded use of plaster was by the Arabian surgeon Avicenna (Abou-Ebn-Sina, ca. 980 to 1036), who studied in Baghdad⁵. In the “Canon of Medicine,” he described linen bandages with calcium oxide (lime from sea shells) and albumen (from egg whites). His principles were based on the writings of Paul of Aegina (652 to 690)³ and were later promoted by the medical school in Salerno, Italy, in the twelfth century^3,4. Bonesetters of this period used circumferential dressings. Albucasis (Abul al-Qasim Khalaf ibn al-Abbas Al-Zahrawi, eleventh century AD, who was considered the greatest Arabian physician of that era and developed many surgical instruments and catgut suture) developed the “coaptation” splint⁵ and was the first to treat femoral shaft fractures with the knee in flexion³.

Guy de Chauliac (1300 to 1370) first recorded the use of traction and splints, quoting Arabian medical texts, Hippocrates, and Galen. In 1363, in “On Wounds and Fractures,” he recommended the Albucasis coaptation splint of willow, sword handle wood, horn, leather, and iron with egg whites. He described tightening the splint with cord and a small rod (similar to Hippocrates’ method), use of a cradle to elevate the limb, and weights for traction with a cord over the patient’s bed to allow independent movement⁸ (see Appendix). Ambrose Paré (1510 to 1590), the famous French military surgeon, strongly advocated de Chauliac’s teachings and devised the hip spica cast^3,4.

During the Middle Ages, bonesetters learned from apprenticeships that used texts by de Chauliac, Arabian surgeons, Galen, and Hippocrates. Bonesetter guilds were separate from medical guilds. Eventually the medical school curriculum adopted fracture care and the bonesetter trade slowly disappeared.

“Plaster of Paris” (calcium sulfate) was introduced in 1798. It was less irritating than calcium oxide (lime) but was difficult to apply. Continued bandage modification combined with the use of ambulation led to modern treatment techniques initiated by four military surgeons: Dominique Jean Larrey, Louis Seutin, Antonius Mathijsen, and Nikolai Ivanovich Pirogov^9,10,12.

Dominique Jean Larrey (1766 to 1842) was present at the storming of the Bastille and served as surgeon-in-chief for Napoleon from 1797 to the Battle of Waterloo in 1815. Larrey organized the first ambulance corps and developed the forerunner of the mobile surgical hospital^4,11,12. At the Battle of Borodino in 1812, he applied a rigid dressing to an infantryman whose arm had been amputated. Three months later, when the dressing was removed, the residual limb was healed. Larrey concluded that the healing had occurred due to leaving the rigid dressing in place. In his “Mémoires de Chirurgie Militaire,” Larrey promoted this concept and the use of camphorated alcohol, lead acetate, and egg whites beaten in water as the optimal bandage-stiffening agent^4,9,12. In 1832, William Beaumont validated Larrey’s approach by creating open fractures in rabbit tibiae and radii and then casting the extremity¹².

The Chief Surgeon for Belgium during the Napoleonic wars, Louis Seutin (1793 to 1865), modified Larrey’s rigid dressing by protecting the limb in wool. Cardboard splints were then cut to size, applied wet, and soaked in a starch solution. Setting required two to three days, and the resulting dressing allowed earlier ambulation and shortened hospitalization. After the Napoleonic wars, Samson Gamgee compiled a complete description of the Seutin technique, having learned it from Seutin himself in France during the winter of 1851 to 1852. This method is the basis of all plaster dressings^1,9,12-14.

Best known for his upper-extremity bandage, Alfred Velpeau (1795 to 1867) was the top French surgeon of his day. Velpeau dramatically reduced the drying time of the Seutin bandage to about six hours by substituting dextrin, a product of starch hydrolysis, for the starch solution^9,10.

Johann Friedrich Dieffenbach (1792 to 1847), a surgeon from Berlin, treated clubfeet with plaster, as did Seutin and Velpeau. He oiled the foot and then placed it in a box with removable sides. An assistant held the foot in the corrected position while plaster of Paris was poured into the box. After the plaster set, the box was dismantled. The surgeon Jules Guerin observed Dieffenbach in Paris in 1832. The Lancet noted Guerin’s success with the technique, and for this reason its development is often attributed to him. However, earlier treatment of clubfoot dates to William Cheselden (1688 to 1752), who held the foot “as near the natural posture” as possible and then wrapped the extremity to just below the knee. The bandage was changed once a “fortnight.”¹⁰

W. Eaton, a British diplomat traveling in Turkey around 1800, noted the use of gypsum molded on linen and applied circumferentially to a fractured extremity⁹. In 1828, doctors in Berlin recorded the alignment of fractured bones in a box to which moist sand was added. Later, calcined gypsum (i.e., plaster of Paris) replaced the sand. However, these heavy casts prevented mobilization.

Two military surgeons independently developed modern plaster dressings. Antonius Mathijsen (1805 to 1878), a military surgeon in the Dutch Army, is credited with development of the modern plaster cast in Haarlem, Holland, in 1851^15,16. He emphasized its simple materials, easy application, custom fit, quick setting, and wound access. The bandage was made of double-folded, unbleached cotton or linen, with dry plaster between the layers. Water was then applied, and the cast was rubbed and contoured until hard. Mathijsen’s 1852 publication described four plaster bandage types: rollers, many-tailed, clamshell splints, and molds⁹. In 1856, use of a plaster bandage became the recommended technique of the Society of Surgery and Obstetrics in Amsterdam and the Society of Physicians in Vienna. It was presented at the Centennial Exhibition in Philadelphia. The bandage is remarkably similar to that of today^7,9,15,16.

Nikolai Ivanovich Pirogov (1810 to 1881), a Professor of Surgery at the Academy of Military Medicine in St. Petersburg, Russia, taught cutting-edge innovations including the use of ether, cross-sectional anatomy, and the use of starched bandages. He introduced female nurses into military hospitals. Although Pirogov was aware of Mathijsen’s technique, his method was based on plaster used in art. He wrapped the limb in a stocking or placed cotton pads on the extremity. The cloth bandages were immersed in a plaster of Paris mixture before application to the limb. By 1837, the Russian Army and Navy adopted the technique, which was used widely during the Crimean War in the 1850s. The Mathijsen technique remained the most popular in Europe and the Americas⁴, yet plaster bandages were not widely used during the U.S. Civil War^9,12. In 1872 Léopold Ollier (1830 to 1900) published the outcome of the plaster immobilization for “war fractures” and promoted its use in the osteogenic role of periosteum^4,17.

During the nineteenth century, use of plaster increased. The first comprehensive English-language text on fractures and dislocations was by Frank Hastings Hamilton (1813 to 1866)³, but he did not advocate routine use of plaster until 1875⁹. Alessandro Codivilla (1861 to 1912) devised “pins in plaster” for acute and malunited fractures at the Rizzoli Institute in Bologna, Italy⁹. With the increased use of plaster, its vulnerability to water became more apparent. In 1851, Utterhoeven made splints from gutta-percha, a rubber-like compound procured from latex from trees in Malaya⁹. By 1860, water-resistant techniques included painting the cast with shellac dissolved in alcohol.

Plaster was increasingly used for fractures and deformities, particularly in the spine. Lewis Albert Sayre (1820 to 1900) published a technique in 1877 for correcting the gibbus deformity of Pott’s disease with use of axial traction through the head and upper extremities and a plaster jacket¹⁸. In 1911, Russell Hibbs (1859 to 1924) reported a case in which a patient underwent a successful spinal fusion (also for Pott’s disease) involving treatment with a plaster jacket and bed rest for eight weeks after the surgery. A removable plaster jacket was required for another six to twelve months. Incorporating the suggestions of John Ridon (1852 to 1936), Hibbs added preoperative spinal correction with use of a plaster turnbuckle. In 1931, his results of the treatment of 360 scoliosis patients showed that the turnbuckle cast was the best method for preoperative correction of the deformity and that fusion was best done early to prevent progression of the curve. This approach transformed the treatment of idiopathic scoliosis and Pott’s disease^13,14,19.

Many consider the Welsh bonesetter Hugh Owen Thomas (1834 to 1891), who is the namesake of the Thomas test, Thomas collar, and Thomas splint, to be the father of British orthopaedic surgery. He was the uncle of Sir Robert Jones, who cofounded the British Orthopaedic Society with two other surgeons in 1894⁴. The Thomas traction splint, first described in 1875 for tuberculosis of the knee, was used extensively in the two world wars for fractures⁹. When Thomas’s nephew, Sir Robert Jones (1857 to 1933), introduced the splint during World War I, the mortality rate for open femoral fractures dropped from >50% to <10% between 1916 and 1918. However, the lower-extremity dressing that bears his name was a bulky cotton dressing that did not have plaster splints^{7,17,18,20,21}. Neither Thomas nor Jones used or advocated the use of plaster because it prevented therapy and was associated with muscle atrophy⁹.

At the end of World War I, the American surgeon Winnett Orr noted that soldiers treated with plaster before transportation back to the U.S. had better healing, reminiscent of Larrey’s observations. He treated osteomyelitis and open extremity fractures by debridement and drainage followed by plaster immobilization. He promoted use of pins in plaster for open fractures^4,9. His concepts and techniques in “Osteomyelitis and Compound Fractures” were published in 1929, depended on plaster immobilization, and were the most successful of their day^4,22 (Fig. 2).

Fig. 2

A man in a body cast, circa World War I (National Museum of Health and Medicine, Reeve Collection 10015).

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In 1939, Trueta published “Treatment of War Wounds and Fractures: With Special Reference to the Closed Method as Used in the War in Spain.”²³ This 137-page text details “the biological technique” as “treatment of open fracture by good surgery followed by immobilization in a plaster cast” in 1073 cases. He attributed this management to Winnett Orr²². Trueta stated that plaster of Paris was “superior to all” splints. In “Principles and Practice of War Surgery,” published in 1943 during the height of World War II, he stressed the importance of plaster to support soft tissues as well as to immobilize the bone. The benefits of plaster dressings were expeditious training in its use, uniformity and ease of application, and the ability to reinforce the dressing. The plaster could be combined with Kirschner wires and traction²⁴. He recommended padding for protection. He found no good solution for the offensive smell from bacteria in the wound; this complication was also a problem for surgeons of later eras^16,23.

Gerhard Kuntscher (1900 to 1972) developed the tibial intramedullary nail in the 1930s and implemented it during World War II. Despite the gradual acceptance and increasing use of this nail, plaster remained the mainstay for tibial fractures and open fractures even during the Vietnam War. Postoperative circumferential casting of war wounds was a radical treatment in the early twentieth century, but it became the standard of care for the open tibial fracture up to the Korean conflict and the Vietnam War, after which it was supplanted by the external fixator (Fig. 3).

Fig. 3

Open tibial and fibular fracture in a long-leg cast with univalve during the Korean War (National Museum of Health and Medicine, WRAIR-KW 58).

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Several innovations were developed to minimize muscle atrophy in the cast. Fedor Krause (1857 to 1937) devised the “walking cast” with minimal padding, plaster casting, and a special “cast shoe” for tibial and fibular fractures⁹. Pierre Delbet (1861 to 1925) modified the technique in 1920 to include use of two plaster splints after closed reduction⁹. Lorenz Böhler developed three principles still used today—reduction, maintenance of reduction, and immobilization. Böhler advocated skintight plaster with active ambulation and occasionally used skeletal traction with unpadded casts for tibial fractures⁹. Hey Groves described a series of ninety-seven patients with leg fractures treated successfully with walking casts proposed by Krause. A special laced boot was used for community ambulation^7,25. An innovator and orthopaedic surgeon, Homer Stryker (1894 to 1980), developed a rubber heel to be integrated into walking casts in 1941 and the oscillating cast saw in 1947. The saw allowed cast removal with greater ease and fewer skin cuts. It also allowed surgeons to make a “window” in the cast over wounds²⁶. Surgeons prescribed weight-bearing and functional activities to minimize the complications. In 1967, Augusto Sarmiento (born 1924) provided criteria and outcomes for a short-leg cast or brace to control rotation, allowing full weight-bearing and knee motion⁹.

Plaster and Synthetic Casting

Use of plaster bandaging increased in the twentieth century, particularly as commercial production improved. In 1900, a “roller” bandage loosely coated with plaster was developed²⁵. Such individually made plaster bandages were widely used in World War I. The Johnson & Johnson Company was the major supplier of commercially produced sterile, prepackaged bandages¹, but plaster still had to be impregnated in the fabric. In 1927 the bandage was improved by the addition of binders (starch, gum, resin, dextrin, and synthetic polymers) to help retain the plaster. In 1931, the first commercial bandages, termed Cellona, were produced in Germany. However, most plaster bandages continued to be made by hand during World War II (Figs. 4 and 5).

Fig. 4

Serving aboard a veteran Navy hospital ship, Ensign Beatrice Rivers of the Navy Nurse Corps supervises preparation of plaster casts for broken limbs on June 8, 1945 (U.S. Navy BUMED Library and Archives 09-8128-11).

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Fig. 5

Casts are applied to a patient from the 163rd Infantry, a casualty from a Japanese landmine explosion on the third day of the invasion of Japan. The operating room is at the 8th Portable Surgical Hospital. The Albee-type orthopaedic table was made by Technician 3rd Class Rudolph Henkel (right foreground), a Surgical Technician from Baltimore, Maryland, out of Japanese pipe, ammunition rods, one piece from a stove pump, and one piece from the windshield of a Jeep (National Museum of Health and Medicine, MAMAS D45-416-78B).

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Trueta and Watson-Jones described patterns of bandage application according to anatomic region. Blount developed techniques specific to the skeletally immature patient²⁷. Watson-Jones developed a technique for plaster splints in which slabs and wedges were used to achieve better alignment as well as a technique for applying traction through the cast²⁸. Perkins detailed use of maximum immobilization, with joints above and below the fracture immobilized to decrease the muscle forces across the joint²⁹. Limiting motion at the fracture site and supporting soft tissues relieves pain. Splints and casts prevent gross motion, protecting the fracture from breaching the soft tissues and from damaging neurovascular structures. Rigid fixation is not achieved as in the case of internal implants^17,28-30.

The “fiberglass” cast was developed in the 1970s to be lightweight, water-resistant, and more radiolucent. The bandage tape is impregnated with polyurethane in a ratio of 45% polyurethane resin to 55% fiberglass. The prepolymer is methylene bisphenyl diisocyanate. Early products required petroleum jelly and use of a lamp to cure the synthetic tape, which was impregnated with a light-activated resin. The first water-activated synthetic cast was produced by Cutter Biomedical²⁶.

To improve water resistance, W.L. Gore & Associates developed water-repellant (waterproof) cast liners, allowing patients to shower and bathe. Use of the liners increases the setting time by about two to three minutes. Commercially available plastic cast covers also offer convenient protection (Tables I and II).

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TABLE I Types of Immobilization Material

Splints

Improvised

Conventional

Basswood

Cramer wire

Thomas

Inflatable

Structural aluminum malleable (SAM) splints

Synthetic

Casts

Plaster

Synthetic

Composite (plaster with synthetic overlap)

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TABLE I Types of Immobilization Material

Splints

Improvised

Conventional

Basswood

Cramer wire

Thomas

Inflatable

Structural aluminum malleable (SAM) splints

Synthetic

Casts

Plaster

Synthetic

Composite (plaster with synthetic overlap)

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TABLE II Examples of Plaster and Synthetic Splints

Upper extremity
Humeral splint (coaptation splint)	Immobilizes the humerus by including the shoulder and elbow³⁹
Posterior elbow splint	May also immobilize the wrist and hand
Sugar tong	Acts as a temporary long-arm cast, immobilizing the wrist in flexion or extension, pronation or supination
Radial or ulnar slab	A radially or ulnarly based splint
Intrinsic plus splint	Immobilizes the metacarpophalangeal joints with the ligaments at maximum length at 90° and the proximal interphalangeal joints held in extension
Gelberman splint	Extension splint for the hand, used for a short duration after acute injury
Lower extremity
Posterior	May extend across the knee or just below it. The knee immobilizer has replaced the long-leg posterior splint. The most common form immobilizes the leg distal to the knee
Seattle (AO) splint	A variation of the traditional bulky Jones dressing applied in a very specific and stepwise manner

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TABLE II Examples of Plaster and Synthetic Splints

Upper extremity
Humeral splint (coaptation splint)	Immobilizes the humerus by including the shoulder and elbow³⁹
Posterior elbow splint	May also immobilize the wrist and hand
Sugar tong	Acts as a temporary long-arm cast, immobilizing the wrist in flexion or extension, pronation or supination
Radial or ulnar slab	A radially or ulnarly based splint
Intrinsic plus splint	Immobilizes the metacarpophalangeal joints with the ligaments at maximum length at 90° and the proximal interphalangeal joints held in extension
Gelberman splint	Extension splint for the hand, used for a short duration after acute injury
Lower extremity
Posterior	May extend across the knee or just below it. The knee immobilizer has replaced the long-leg posterior splint. The most common form immobilizes the leg distal to the knee
Seattle (AO) splint	A variation of the traditional bulky Jones dressing applied in a very specific and stepwise manner

Francis Whyte invented cast spacers (U.S. patent 3643657) for short-leg casts in 1972. It is important to split casts (univalve or bivalve) in the presence of swelling or prior to air travel (as a change in atmospheric pressure affects limb edema).

The Chemistry of Casts

Plaster of Paris is named for the large gypsum deposit at Montmartre in Paris, France. It is calcined gypsum based on the hemihydrate of calcium sulfate, and it results when gypsum is heated to about 300°F (150°C). Fabric impregnated with plaster of Paris and starch is used to form a cast. Water is added to the plaster powder in the presence of a catalyst such as potassium sulfate or alum, resulting in the formation of calcined gypsum. The reaction speed is reduced with the addition of sodium borate or sodium chloride. Water expands plaster by approximately 0.5%. Setting starts about ten minutes after water exposure and is complete at forty-five minutes. Drying requires seventy-two hours for completion. The bandage may be stiffened by adding dextrose or starch^7,31,32.

An exothermic reaction results when plaster or synthetic casts are placed in water. For plaster, the soluble form of calcium sulfate returns to its insoluble form: Image Not Available

For synthetic casting, the prepolymer converts to the polyurethane polymer: Image Not Available

The heat of reaction and setting temperature are affected by several variables. Setting temperatures were investigated by Lavalette et al. in 1982³¹. The temperature of the casting material was greatest (180°F or 82°C) when the plaster was at 122°F (50°C). Temperatures for synthetics were lower, ranging from 91°F (33°C) for Scotchcast (3M, St. Paul, Minnesota) to 102°F (39°C) for Ultracast (Zimmer, Warsaw, Indiana). The factors associated with burns were a dip water temperature of >75°F (24°C), use of more than eight layers (ply), and use of a pillow (inadequate ventilation). Plaster residue in the dip water did not increase the exothermic reaction. Temperatures were increased under all conditions for extra-fast-drying (quick-set) plaster. Heat loss was greater from the outer surface of the plaster because of evaporative cooling. Moisture on the outside of the cast decreased the temperature of the plaster. The maximum temperature for an eight-ply cast was greater for plaster than for synthetic materials³¹.

Recently, Halanski et al. evaluated circumferential casts and L-shaped splints of plaster, fiberglass, and composites³³. The surface of the cast was 2.7° ± 1.9°C cooler than the internal temperature. A dip water temperature of <24°C did not result in a temperature high enough to cause burns, regardless of the number of layers. A dip water temperature of >50°C, a twenty-four-ply cast thickness, use of a plastic pillow, overwrapping of a curing plaster cast with synthetic, and use of a splint folded on itself were associated with temperatures causing burns³³.

Application

Modern anesthesia, antisepsis, and metallurgy have combined to make the operative management of many fractures safe and efficacious. However, both prospective and retrospective studies support the nonoperative treatment of many fractures with casting. Inherent in this management strategy is the concept that not all fractures require anatomic alignment and reduction for excellent functional outcome. The concepts of fracture treatment with casts or splints are maintenance of an acceptable reduction, achievement of a normal appearance of limb alignment (length, angulation, and rotation), and restoration of function within a reasonable period. Among congenital disorders, clubfoot is routinely treated by a stepwise casting process to address the individual deformities. Promoted by Kite and perfected by Ponseti, this method is the most successful nonsurgical management of clubfoot, with extremely favorable long-term outcomes^34,35.

Plaster may be applied with use of two general techniques. The first is to apply the plaster directly to the skin without a material such as Webril (Covidien, Mansfield, Massachusetts), padding, or a stockinette, i.e., the total-contact cast. The second is application over protection. The Bologna cast is rolled under tension with Webril. This method is similar to skin traction. The modern cast uses a stockinette followed by Webril and then plaster rolled by overlapping the layers by one-third or in a basket-weave pattern. Large, custom slabs may be used to reinforce the cast. The materials are similar to those used seventy years ago^16,36. Pins in plaster and nonrigid internal fixation (flexible nails) may also be combined with a splint or cast. Currently, a splint may be used along with an external fixator or traction pin to promote soft-tissue rest.

Molding is necessary to maintain the soft-tissue “hydraulics” and to prevent the cast from shucking. Better contour and contact may be achieved by molding with use of a straight edge on a subcutaneous bone, such as the ulna. On radiographs, the cast index and the gap index may be used. The gap index is a better predictor of cast failure and is more sensitive than the cast index³⁷.

Plaster has certain technical advantages over synthetics. Plaster can be tucked or pleated. Plaster requires less tension for application. Gloves are not required. Plaster absorbs fluids, including pus, blood, and sweat. If a cast saw is not available, the plaster cast may be removed by soaking and hand-cutting or unrolling. However, compared with fiberglass, plaster may be difficult to store in humidity and is more difficult to keep clean. Plaster casts are heavier than fiberglass, exhibit more breakdown for short-leg casts, and are judged to be more restrictive as well as less comfortable³⁸.

There are many disadvantages of any type of splinting or casting compared with other methods of fixation. When treated with casting, some fractures have suboptimal outcomes, i.e., poor healing rates, malalignment, loss of reduction, and disability. Other complications are (pressure) sores, compartment syndrome, thrombophlebitis, and cast burns. Cast sores result from pressure, and irreversible damage may occur from a tight dressing after two hours. To prevent compartment syndrome, care must be taken in children and in patients with soft-tissue injury (including burns), multiple trauma, paralysis or paresis, head injury, or altered sensorium (due to medications, substance abuse, or psychosis). Evaluation of neurovascular status and recording of abnormalities are essential. Circumferential casting is contraindicated in patients with abnormal vascular status⁷. Thermal burns are directly related to the exothermic reaction caused by mixing the casting with water. They are best prevented by using water cooler than 72.5°F (24°C), using eight or fewer plies, keeping the plaster moist, and using padding liberally³¹. Burns may result from urine in contact with the cast, and this is a problem with hip spica casts. Problems associated with immobilization, including cartilage desiccation, osteopenia, muscle atrophy, and insertional weakness of tendons and ligaments, are inherent. Cast syndrome, associated with body jacket casts, involves obstruction of the third portion of the duodenum from duodenal constriction caused by stretching of the superior mesenteric vessels; symptoms are nausea, vomiting, fever, and electrolyte imbalance. Infection may occur by contamination of the wound by plaster, Webril, or dip water.

Conclusions

Despite the advances in internal fixation, rigid splints and casts remain a part of our orthopaedic armamentarium. The modern plaster cast dates to Mathijsen in 1852 and relies on immobilization principles and soft-tissue rest described by de Chauliac in 1363. Casts and splints are part of our orthopaedic heritage and constitute cost-effective management for a number of conditions in adults and children.

Appendix

An excerpt from de Chauliac’s “Fifth Treatise on Fractures and Dislocations” describing the principles of fracture treatment is available with the online version of this article as a data supplement at jbjs.org.

Acknowledgements

Note: The authors thank Kathryn Foster, Casey Price, HM3 Dustin Harvey, USN, and John Kopitzke (Visual Information Department, Naval Medical Center Portsmouth); HM2 Tristan Bactat, USN (Department of Orthopaedic Surgery, Naval Medical Center Portsmouth); Matthew Shea (Office of the General Counsel, Department of the Navy); and Kenneth Hubbard and Charles Kittrell (Pediatric Orthopaedics and Scoliosis Associates).

Sherk H. Getting it straight: a history of American orthopaedics. Bucholz RW; Hamilton JH, editors. Rosemont, IL: AAOS; 2008. Fractures and dislocations; p 81-116.

Smith GE. The most ancient splints. Br Med J. 1908 Mar 28;1( 2465):732-736. 2.[CrossRef]

Peltier LF. Fractures: a history and iconography of their treatment. San Francisco: Norman Publishing; 1990. The literature of fractures; p 13-61.

Trueta J. The principles and practice of war surgery. London: Hamish Hamilton Medical Books; 1943. The development of war surgery; p 23-44.

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Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Topics

fracture ; bandage ; casts, surgical ; interosseous desmitis ; plaster

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Kamyar Ghabili, Samad EJ Golzari

Posted on October 30, 2012

Plaster for musculoskeletal conditions in medieval Persia

Physical Medicine and Rehabilitation Research Center, Tabriz University of Medical Sciences, Tabriz, Iran

We read with great interest the review paper of DeMaio et al. outlining the history of immobilization materials particularly plaster. They indicated that Avicenna, who studied in Baghdad, first used plaster as a stiffening agent to treat fractures. Firstly, to the best of our knowledge, the medieval Persian physicians including Rhazes (865-925 AD) and Avicenna used plaster as stiffening agent for the treatment of nerve injuries rather than bonesetting. Secondly, Abu Ali Husain ibn Abdullah ibn Sina, known as Avicenna, was born to a Persian family in Afshaneh, a village near Bukhara (now located in Uzbekistan), in Persia. Until the age of nineteen (999 AD), Avicenna studied and practiced medicine in Bukhara. Throughout his life, Avicenna travelled to different Persian cities including Gorganch (now known as Urgench in Uzbekistan), Ray, Hamadan and Isfahan. On the way back to Hamadan from Isfahan in 1037, Avicenna suffered from severe colic, perhaps due to stomach cancer, and died at the age of 58. Altogether, in contrast to what indicated by DeMaio and colleagues, Avicenna had never been to Baghdad. We suggest the authors elucidate these discrepancies in their historical review to provide more accurate information on the history of plaster.

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Marlene DeMaio, Kathleen McHale, Martha Lenhart, Joshua Garland, Christopher McIlvaine, Michael Rhode; Plaster: Our Orthopaedic HeritageAAOS Exhibit Selection. The Journal of Bone & Joint Surgery. 2012 Oct;94(20):e152 1-8.

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