Above elbow backslab - Living on the EDge

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Casting: above-<strong>elbow</strong> back slabs
Mary Drozd and colleagues continue their
series on good practice in casting with a review
of the application of above-<strong>elbow</strong> back slabs
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July 2009 | Volume 17 | Number 4
Summary
This article continues a short series of articles on
how to apply casts. It examines how above-<strong>elbow</strong>
back slabs should be applied following fracture of
the forearm, <strong>elbow</strong> and distal humerus.
Keywords
Fracture, forearm, back slab
The indications for applying an above-<strong>elbow</strong>
(AE) back slab include the following fractures of
the forearm, <strong>elbow</strong> and distal humerus:
■■
Fractures of the radius and ulna.
■■
Ulnar fracture with radial dislocation and
rupture of the annular ligament, known as
Monteggia’s fracture.
■■
Wrist fracture with volar displacement and
angulation of the distal bone fragment,
known as Smith fracture.
Box 1
Materials required for above-<strong>elbow</strong> back slabs
■■
A bowl of warm water for washing patients’ skin.
■■
A towel.
■■
A tape measure.
■■
Plaster of Paris bandages or slabs,
15cm and 10cm wide.
■■
Bandage scissors.
■■
Stockinette, 7.5cm wide.
■■
Padding, 7.5cm and 10cm wide.
■■
A bucket of warm water.
■■
A plastic apron, plastic covered pillows and
protective plastic sheeting.
■■
Crêpe or cotton conforming bandages, 10cm wide.
■■
Plaster strips or waterproof tape.
■■
A triangular sling.
■■
Information leaflets on plaster care and exercise.
■■
A rubbish bag.
■■
Distal radial fracture with dislocation of the
radioulnar joint, known as Galeazzi’s fracture.
■■
Supracondylar fractures of the humerus.
■■
Injuries around the <strong>elbow</strong>.
In all these cases, an AE back slab can be applied
in the first instance because it allows room for
the expected swelling after acute injury.
Preparation
Preparation of the patient and the equipment is
necessary to make the application of the back
slab as tolerable and as efficient as possible
(Lucas and Davis 2005).
Assessment of the patient’s pain level
should be documented and pain should be
managed appropriately.
As well as medication, non‐pharmacological
adjuncts to pain relief such as the use of a sling
should be considered (Lucas 2005).
Box 1 lists the materials required for an AE back
slab (Miles et al 2000, Prior and Miles 1999).
The patient’s <strong>elbow</strong>, forearm and wrist should
be supported in a position requested by the nurse
practitioner or doctor. This will be the position in
which the cast is to remain.
The <strong>elbow</strong> should not be bent after the wool
padding or plaster is applied (Goldie 1997) to ensure
that ridges do not form inside the cast and cause
pressure damage.
The affected upper limb should be positioned
so that the <strong>elbow</strong> is supported at 90° flexion. The
forearm should be in mid-supination, or pronation,
so that the patient’s palm faces the body, and the
wrist is in the neutral position.
For Smith fracture however, the forearm should
be in full supination so that the palm faces upwards
and the wrist is in dorsiflexion.
As a general rule, 15cm-wide slabs are used for
posterior slabs and 10cm-wide slabs are used for
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Feature
medial and lateral slabs, although slab size depends
on the size of the patient.
Slabs should cover about two thirds of the
circumference of the patient’s forearm and should
not meet on the anterior aspect.
Method of application
1. The length between the axilla and metacarpal
heads is measured to assess the length of the
15cm-wide posterior slab (Figure 1).
2. One 15cm-wide slab with about seven layers
and two 10cm-wide, 25cm-long slabs, each with
five layers, are prepared (Figure 2). Either plaster
slab or plaster bandages that are cut to size are
used for all three slabs. The number of layers of
the posterior slab depends on the patient. For
example, a frail, older person needs fewer layers
than a fit teenager, and would prefer the back
slab to be as light as possible.
3. Stockinette can be applied if the fracture is not
being manipulated or if there is no profound
swelling. The stockinette must be the correct size
and rolled gently onto the limb (Figure 3).
4. Under-cast padding should be applied firmly
and evenly in a single layer, but with extra layers
applied around bony prominences such as the
ulnar styloid, olecranon and medial epicondyle.
The use of padding allows for swelling and
reduces friction between the cast and the skin
(Lucas 2005). The padding should be placed 3cm
beyond the intended extent of the slab to protect
the skin (Figure 4).
5. The 15cm-wide plaster slab is folded and
dipped into the bucket of water at a temperature
of about 25°C. If the water is too cold, the
setting process is too slow; if it is too hot,
the patient may be burned. After about four
seconds, the slab is removed and excess water
is squeezed out gently.
6. The 15cm-wide plaster slab is applied to the
posterior aspect of the arm (Figure 5). A plastic
apron, plastic-covered pillows and protective
plastic sheeting may be needed to ensure the
patient does not become wet.
7. If the stockinette is being used, it should be
folded over at each end of the posterior slab.
8. The 10cm-wide slabs are soaked in a similar way
to the 15cm-wide slab, and are applied along the
medial and lateral aspects of the <strong>elbow</strong> joint. The
two slabs should not meet on the anterior aspect
(Figure 6).
9. Pre-soaked crêpe or cotton bandage is wrapped
around the slabs and secured with plaster strips
on the plaster slab only (Figure 7). Pre-soaking
ensures the bandage does not shrink, stick onto
the wet plaster and tighten around the limb.
It can also ensure that the bandage is easy to
remove on the patient’s return to clinic.
Figure 1
The length between the axilla and
metacarpel heads is measured
Figure 2
One 15cm-wide slab and two 10cm-wide
slabs are prepared
Figure 3 Stockinette can be applied Figure 4 Under-cast padding is applied
Neil O’Connor
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Feature
Figure 5
The 15cm-wide slab is applied to the
posterior aspect of the arm
Figure 6
The 10cm-wide slabs are applied along
the medial and lateral aspects of the <strong>elbow</strong>
Figure 7
Pre-soaked crepe or cotton bandage is
applied and secured with plaster strips
Figure 8
A triangular sling is applied
10. A triangular sling is applied (Figure 8).
11. Patients are given verbal and written advice
on plaster care, and on hand, shoulder and
finger exercises that can prevent joints from
stiffening and weakening. They are asked to
sign for the written advice and to indicate
that they have received and understood the
verbal advice. The questioning of patients
about this advice should elicit their levels
of understanding.
12. Unused plaster slab, padding or bandage is
thrown away in the rubbish bag.
Assessment and advice
Signs of vascular or neurological damage should
always be checked for, both before and after
back slabs are applied, by observation of the
colour, movement, sensation and warmth of
the limb distal to the injury (Jones 2003, Judge
2007). This ensures that the application has not
compromised the limb.
References
Supracondylar fractures of the humerus, for
example, can injure the brachial artery so radial
pulse must be checked carefully. These serial
assessments of vascular and neurovascular status
must be documented in the patient’s notes (Bethel
2008, Nursing and Midwifery Council 2002).
Finally, a fracture clinic appointment should be
arranged for follow-up treatment.
Implications for practice
To undertake above-<strong>elbow</strong> back slab casting,
practitioners must be trained, competent and
possess the underpinning knowledge. They must
understand the relevant anatomy, injuries and
complications that may follow application of a cast.
Further reading
In September’s Emergency Nurse, the authors will
look at below-<strong>elbow</strong> back slab casting.
Mary Drozd is a senior
lecturer at the School
of Health, University
of Wolverhampton,
and an advanced nurse
practitioner in trauma
and orthopaedics at
the Dudley Group
of Hospitals
NHS Foundation Trust
Sue Miles is a national
casting training advisor
at the British Orthopaedic
Association
Jenny Davies is a
senior sister in the
surgical and trauma and
orthopaedic outpatient
department and casting
service at Russells Hall
Hospital, the Dudley
Group of Hospitals
NHS Foundation Trust
Bethel J (2008) Paediatric Minor Emergencies.
M&K Publishing, Keswick.
Goldie BS (1997) Orthopaedic Diagnosis and
Management: A guide to the care of orthopaedic
patients. Second edition. Isis Medical
Medic, London
Jones G (2003) Emergency care of the
person with minor injury and minor
illness. In Jones G, Endacott R, Crouch R
(Eds) Emergency Nursing Care: Principles and
practice. Greenwich Medical Media, London.
Judge NL (2007) Neurovascular assessment.
Nursing Standard. 21, 45, 39-43.
Lucas B (2005) Care of patients with upper
limb injuries and conditions. In Kneale J,
Davis P (Eds) Orthopaedic and Trauma Nursing.
Second edition. Churchill <strong>Living</strong>stone, London.
Lucas B, Davis P (2005) Why restricting
movement is important. In Kneale J, Davis P
(Eds) Orthopaedic and Trauma Nursing.
Second edition. Churchill <strong>Living</strong>stone, London.
Miles S, Burden JW, Prior M et al (2000)
A Practical to Casting. BSN Medical, Hull.
Nursing and Midwifery Council (2002)
Guidelines for Records and Record Keeping.
NMC, London.
Prior M, Miles S (1999) Principles of casting.
Journal of Orthopaedic Nursing. 3, 3, 162-170.
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July 2009 | Volume 17 | Number 4
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