The Journal
Volume 9, Issue 1

OVERVIEW

For the orthopaedic technologist, casting is a part of everyday life, and cast removal is one half of that job. Of course, there
is much to know to have skilled efficiency with this procedure. Materials, tools, and techniques are all important, as is maintaining the comfort of the patient. The following clinical protocol for cast removal will help you develop your skill
level, whether this is your introduction to cast removal or merely a review.

A BRIEF HISTORY

For many centuries, broken bones have plagued mankind. Various materials were used for immobilization in treating
these injures, such as gum/linen mix, mud or clay, and
plaster-impregnated cotton. For over a century, plaster of
Paris rolls were the standard of care for treating broken
bones and other orthopaedic injuries. Within the past 30 years, though, synthetic materials such as fiberglass or polyester cloth impregnated with resin have replaced plaster of Paris bandages as the primary material for immobilization.

Several rather simple methods were used to remove these early casts. Initially, a sharp knife was used, but this was often hazardous for the patient and the practitioner. Later, scissors
or plaster shears were used to remove the hardened bandages. They made removal safer and easier but gave the practitioner quite a workout. Plaster of Pairs casts were routinely removed by soaking them in water or a water/vinegar solution and then unrolling them. Unfortunately, this was often a very time-consuming and frustrating process.

In 1943, a revolutionary tool was invented by Dr. Homer Stryker of Kalamazoo, Michigan. Noting the difficulty the orthopaedic practitioner had with removing a cast by hand
or soaking, he devised an electrically powered oscillating saw
to cut and remove a cast.

Instead of laboring with a pair of plaster shears or having patients soak their limbs for hours, he could now cut the
plaster of Paris bandage rather easily with the vibrating saw blade. Even though it was noisy, the new cast saw significantly reduced the time it took to remove a cast. Since that time,
the oscillating electric cast saw has been the tool of choice for cast removal.

MODERN CAST CUTTERS

Today there are several different types of cast cutters available, making the daunting task of removing casts with shears a thing of the past. Most are electrically powered, but others are pneumatically powered by a high-pressure air source. Both portable and fixed systems are in use, and different blades are available to cut different casting materials. Stainless-steel blades are used for plaster of Paris, but they
do not work well with synthetics. Special blades that produce less friction, such as dicronite, titanium nitride, or Teflon, are recommended for synthetic materials.

EVOLVING CAST MATERIALS

Orthopaedic medicine is almost as old as the human race.
Fossil evidence suggests primitive humans likely devised ways to immobilize and support fractured limbs. The ancient Egyptians made splints out of bamboo padded with linen and invented crutches. Ancient Greek physician Hippocrates had
a thorough understanding of fractures and developed special splints for fractures of the tibia, similar to external fixation. Arab practices introduced the use of plaster of Paris for immobilization in the 10th century, and 10 centuries later, synthetic materials such as fiberglass became the staple
of the modern cast’s make-up.

The cast cutter consists of an oscillating blade that moves
back and forth about a quarter of an inch. It does not rotate like a circular saw blade. The blade will not cut anything soft, like cast padding or skin; however, hard objects are fair game.

The oscillating blade also reduces the amount of dust generated compared with a circular blade. Most cast cutters are equipped with vacuum systems to filter dust from all types of casts. To assure the efficiency of the cutting system, it is important to keep the vacuum filter system cleaned and well maintained.

CAST REMOVAL PROCEDURE

Step 1: Assemble the cast cutter, cast spreaders, and scissors.

Step 2: Explain the operation of the cast cutter to the patient. Demonstrate on your own hand how the saw works and that
it will not harm soft tissue. This is crucial when dealing with children, as the sounds of the saw and vacuum can elevate their level of anxiety. The use of earplugs or headphones is valuable in reducing the noise exposure.

Step 3: Although vacuum systems will capture most of the fiberglass dust during cast removal, some particles may transfer inadvertently to the eyes. To protect the eyes from injury, goggles or safety glasses are recommended for both
the patient and the practitioner.

Step 4: Position the patient on the exam table so the cast is accessible to you but also in a comfortable position for the patient. Grip the cast cutter close to the blade end so the saw feels balanced in the hand. Use your thumb or index finger as
a guide to measure the depth of the blade’s penetration into
the cast.

Step 5: Begin cutting from the proximal end of the cast and move along to the distal end (for an arm cast, the elbow to
the fingers; for a leg cast, the groin or knee to the toes). This motion allows the practitioner to move the saw toward his or herself and gain better control. Use an up-and-down motion as you move along the length of the cast, keeping the blade in the cutting groove. When the blade penetrates the cast wall, you will no longer feel resistance. This is the signal to bring the blade up and out and continue with the cutting motion. Trust your hands as well as your eyes.

The cast should be bivalved, or cut on opposite sides, for
easier removal, For a leg cast, make one cut below the lateral malleolus and the opposite cut above the medial malleolus.
This will protect these bony prominences from injury. For
spica casts, additional cuts are sometimes necessary.

Never push or drag the blade, as this motion will increase friction and heat the blade, which can burn the patient. Monitor the cutting process by asking the patient if he or she is detecting any increase in temperature at the cutting site. Cutting a “green” cast will also cause the blade to heat up, as the blade can become clogged with wet plaster or uncured resin. If you must remove a freshly applied cast, wait until the cast curing process is complete, which may take from 10 to 20 minutes.

If the cast is too thick to cut completely through, continue to
the end of the cast. Then go back over the thick area again until you can cut through. Be careful not to stay in one area
too long, as this too, will cause the blade to heat up.

It is important to use both hands equally well when using a
cast cutter. There may be times when using your dominant hand is not practical because of the position of the patient, requiring that you use your other hand to operate the cutter.

Step 6: After the cast is bivalved, use the cast spreader to “pop” the cast open wide enough to cut the underlying padding with scissors. Begin with the distal end and cut the stockinet around the upper end of the cast from one bivalved cut to another. Gently pull the cast away from the arm or leg, using the attached proximal end as a hinge. This will free the cast from the padding.

Next, cut the stockinet at the proximal end and remove the
free cast section, exposing underlying padding. Now the padding can be easily cut and removed. This will provide
easier cutting than cutting through the padding and stockinet along
the bivalved split.

Step 7: Carefully remove the cast and dispose of it immediately. To avoid spreading dust particles, do not handle the removed cast more than necessary. In addition, splinters
of fiberglass from the cut cast edges are often sharp and can cause penetrating wounds to the skin. Examine the limb for bruises or lesions. Remove dead skin or dirt with soap and water, rubbing alcohol, or after-cast lotion.

Step 8: Following patient discharge, check the area and
collect all dust particles for disposal. Prepare equipment
for the next use.

PRACTICE PROCEDURE

For a novice, cutting a cast on your own arm is a good way
to learn how the cast cutter works and experience how it feels when used on a patient. Have a coworker apply a cast on your non-dominant arm. When cured, take the cutter in your dominant hand and bivalve the cast. You will feel in your hand the resistance of the cast being cut, and on your arm you’ll feel what the patient experiences during cast removal. You can practice cutting a cast with your non-dominant hand by reversing the procedure.

CONCLUSION

Rolling into the 21st century, the orthopaedic technologist should remain on the cutting edge of technology. Casting is
still an important part of orthopaedics, and the modern cast cutter is a vital tool for cast removal. Knowing how it works
and how to use it will make your job easier and make you a “cut above” the rest. NAOT

Steven Cutler is a certified orthopaedic technologist employed by Orthopedic Associates of Lancaster, Pennsylvania. He has
25 years experience in the application of casting materials and is a member of NAOT as well as an associate member of CSOT.