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Introduction ⬇

A practitioner will typically remove a cast when a fracture heals or requires further manipulation. Less common indications include cast damage, a pressure injury under the cast, excessive drainage or bleeding, and a constrictive cast. X-rays are commonly obtained before or after cast removal to ensure that the fracture has healed properly.1

Cast removal requires making two parallel longitudinal cuts through several layers of casting material. The practitioner uses a cast saw to perforate the plaster or fiberglass casting material and then separates the material with a cast spreader. Then, the practitioner cuts the padding and stockinette layers with cast scissors.2

Equipment ⬆ ⬇

Equipment

Fluid-impermeable pads ▪ cast spreader ▪ cast saw (preferably with vacuum attachment) ▪ cast scissors ▪ washcloth ▪ towel ▪ soap and water ▪ facility-approved disinfectant ▪ Optional: masks and goggles, skin care supplies, ear protection.

Preparation of Equipment ⬆ ⬇

Preparation of equipment

Inspect all equipment and supplies. If a product is expired, is defective, or has compromised integrity, remove it from patient use, label it as expired or defective, and report the expiration or defect as directed by your facility.

Ensure that the cast saw operates properly before use and that the blade is sufficiently sharp to cut through the cast. Follow the manufacturer’s recommendations for use and care of the cast saw.

Implementation ⬆ ⬇

Implementation
  • Verify the practitioner’s order.
  • Gather and prepare the necessary equipment and supplies.
  • Perform hand hygiene.3,4,5,6,7,8
  • Confirm the patient’s identity using at least two patient identifiers.9
  • Provide privacy.10,11,12,13
  • Explain the procedure to the patient and family (if appropriate) according to their communication and learning needs to increase understanding, allay their fears, and enhance cooperation.14 Tell the patient that the cast saw uses an oscillating blade that is designed to avoid cutting the skin, and that the patient should expect to feel some vibration and warmth when the saw cuts the cast, but must report discomfort or excessive warmth immediately during the procedure.15 Explain that the patient must remain still during the procedure to prevent injury.15 Tell the patient that after cast removal, the skin may be flaky and discolored, and the muscle may be diminished, stiff, and weak.15
  • Raise the bed to waist level before providing care to prevent caregiver back strain.16
  • Perform hand hygiene.3,4,5,6,7,8
  • Assist the patient into a comfortable position that will allow access to the cast. For a lower limb cast, the patient should be lying down. For an upper extremity cast, the patient may be seated or lying down.17
  • Cover the appropriate parts of the patient’s bedding with fluid-impermeable pads.
  • If the cast saw doesn’t have a vacuum attachment to dispose of the cast dust during removal, put on a mask and goggles during the procedure and assist the patient and anyone else present with putting on a mask and goggles to prevent inhalation and irritation from particulate cast material.
  • If needed, put on ear protection and assist the patient and anyone else present with putting on ear protection to protect against hearing loss and reduce anxiety.18,19,20
  • Assist the practitioner as needed with removing the cast. The practitioner will cut one side of the cast (as shown below) and then the other.2 The practitioner will open the cast with a cast spreader and then use cast scissors to cut through the cast padding on each side and then proceed with cutting the stockinette.2

  • Monitor that patient’s anxiety level as the practitioner removes the cast. Provide emotional support, as needed.
  • Support the extremity and inspect the patient’s skin for burns, abrasions, lacerations, and pressure injuries. Provide skin care as appropriate.
  • Wash the affected limb with soap and water and dry it thoroughly with a towel to remove the accumulated dead skin.17
  • Remove your ear protection and mask and goggles, if worn, and assist the patient and others in doing the same, as needed.21
  • Discard used supplies in appropriate receptacles.21
  • Return the bed to the lowest position to prevent falls and maintain the patients safety.22
  • Perform hand hygiene.3,4,5,6,7,8
  • Put on gloves and other personal protective equipment, as needed.21
  • Clean and disinfect reusable equipment according to the manufacturer’s instructions to prevent the spread of infection.23,24
  • Remove and discard your gloves and other personal protective equipment, if worn.21
  • Perform hand hygiene.3,4,5,6,7,8
  • Document the procedure.25,26,27,28

Special Considerations ⬆ ⬇

Special considerations
  • If the patient reports pain or heat during cast removal, the practitioner must discontinue saw use and cool the blade before resuming to reduce the risk of thermal injury. Poor cutting technique (such as the cast saw blade never leaving the cast material during cutting), fiberglass casting material, and thinner cast padding can result in significantly higher skin temperatures. Techniques for reducing the temperature of the oscillating saw blades during cast removal include cooling the blade in the ambient air, using a vacuum attachment, and applying 70% isopropyl alcohol or water to the blade with a gauze pad. These techniques decrease the risk of skin burns.29

Patient Teaching ⬆ ⬇

Patient teaching

Tell the patient to avoid rubbing or scratching the skin, because doing so can damage the newly exposed skin. Teach the patient how to perform skin care after the cast is removed. Advise the patient to follow the practitioner’s instructions regarding how much and what type of activity to engage in after cast removal.15

Complications ⬆ ⬇

Complications

The practitioner may accidentally injure the patient’s skin with the cast saw, scissors, or spreader. Thermal injury may also occur due to the heat generated by the cast saw.29

Documentation ⬆ ⬇

Documentation

Record the date and time of cast removal and the patient’s tolerance of the procedure. Document your neurovascular and skin assessment findings after cast removal; include any care provided. Note any complications from the procedure, your interventions, and the patient’s response to those interventions. Document teaching provided to the patient and family (if applicable), their understanding of that teaching, and any need for follow-up teaching.

References ⬆

  1. BeutlerA., & TitusS. (2019). General principles of definitive fracture management. In: UpToDate, EiffP., & AplundC. A,. (Eds.).
  2. HinkleJ. L., & CheeverK. H. (2017). Brunner & Suddarths textbook of medical-surgical nursing (14th ed.). Philadelphia, PA: Wolters Kluwer.
  3. The Joint Commission. (2021). Standard NPSG.07.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  4. Centers for Disease Control and Prevention. (2002). Guideline for hand hygiene in health-care settings:

    Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force

    . MMWR Recommendations and Reports, 51(RR-16), 1–45. https://www.cdc.gov/mmwr/pdf/rr/rr5116.pdf (Level II)
  5. World Health Organization. (2009). WHO guidelines on hand hygiene in health care: First global patient safety challenge, clean care is safer care. https://apps.who.int/iris/bitstream/handle/10665/44102/9789241597906_eng.pdf (Level IV)
  6. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:

    Infection control. 42 C.F.R. § 482.42

    .
  7. Accreditation Association for Hospitals and Health Systems. (2020). Standard 07.01.21. Healthcare Facilities Accreditation Program:

    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  8. DNV GL-Healthcare USA, Inc. (2020). IC.1.SR.1. NIAHO accreditation requirements, interpretive guidelines and surveyor guidancerevision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)
  9. The Joint Commission. (2021). Standard NPSG.01.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  10. The Joint Commission. (2021). Standard RI.01.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  11. DNV GL-Healthcare USA, Inc. (2020). PR.1.SR.5. NIAHO accreditation requirements, interpretive guidelines and surveyor guidancerevision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)
  12. Accreditation Association for Hospitals and Health Systems. (2020). Standard 15.01.16. Healthcare Facilities Accreditation Program:

    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  13. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:

    Patient’s rights. 42 C.F.R. § 482.13(c)(1)

    .
  14. The Joint Commission. (2021). Standard PC.02.01.21. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  15. SatrybS. A., et al. (2011). Casting:

    All wrapped up

    . Orthopaedic Nursing, 30(1), 37–41.
  16. WatersT. R., et al. (2009). Safe patient handling training for schools of nursing. https://www.cdc.gov/niosh/docs/2009-127/pdfs/2009-127.pdf (Level VII)
  17. SinghA. P. (n.d.). Removal of plaster casts. https://boneandspine.com/removal-of-plaster-casts/
  18. Occupational Safety and Health Administration. (n.d.). Occupational noise exposure, standard number 1910.95. https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.95 (Level VII)
  19. MarshJ. P., et al. (2011). Noise levels in adult and pediatric orthopedic cast clinics. American Journal of Orthopedics, 40(7), e122–e124. https://www.researchgate.net/publication/51732261_Noise_levels_in_adult_and_pediatric_orthopedic_cast_clinics (Level VI)
  20. MahanS. T., et al. (2017). Noise reduction to reduce anxiety during cast removal:

    Can we decrease patient anxiety with cast removal by wearing noise reduction headphones during cast saw use?

    Orthopedic Nursing, 36(4), 271–278. (Level VI)
  21. Occupational Safety and Health Administration. (2012). Bloodborne pathogens, standard number1910.1030. https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=10051&p_table=STANDARDS (Level VII)
  22. GanzD. A., et al. (2013, reviewed 2021). Preventing falls in hospitals:

    A toolkit for improving quality of care

    (AHRQ Publication No. 13-0015-EF). Rockville, MD: Agency for Healthcare Research and Quality. https://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/index.html (Level VII)
  23. Accreditation Association for Hospitals and Health Systems. (2020). Standard 07.02.03. Healthcare Facilities Accreditation Program:

    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  24. RutalaW. A., et al. (2008, revised 2019). Guideline for disinfection and sterilization in healthcare facilities, 2008. https://www.cdc.gov/infectioncontrol/pdf/guidelines/disinfection-guidelines-H.pdf (Level I)
  25. The Joint Commission. (2021). Standard RC.01.03.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  26. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:

    Medical record services. 42 C.F.R. § 482.24(b)

    .
  27. Accreditation Association for Hospitals and Health Systems. (2020). Standard 10.00.03. Healthcare Facilities Accreditation Program:

    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  28. DNV GL-Healthcare USA, Inc. (2020). MR.2.SR.1. NIAHO accreditation requirements, interpretive guidelines and surveyor guidancerevision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)
  29. PuddyA. C., et al. (2014). Cast saw burns:

    Evaluation of simple techniques for reducing the risk of thermal injury

    . Journal of Pediatric Orthopaedics, 34(8), e63–e66. (Level VI)