What are the recommended plaster positions for upper and lower limb fractures to prevent complications?

Recommended Plaster Positions for Upper and Lower Limb Fractures to Prevent Complications

For optimal fracture healing and prevention of complications, limb fractures should be immobilized in functional positions that maintain proper alignment while preventing contractures, neurovascular compromise, and soft tissue damage.

Upper Limb Fracture Positions

Wrist/Distal Radius Fractures

• Position: Slight wrist extension (20-30°), slight ulnar deviation, neutral forearm rotation
• Immobilization: Forearm cast extending from below elbow to metacarpal heads
• Rationale: This position maintains reduction while preserving functional hand position 1
• Duration: 4-6 weeks depending on fracture stability and healing

Forearm Fractures

• Position: Elbow flexed at 90°, forearm in neutral or slight supination
• Immobilization: Above-elbow cast with elbow at 90° flexion
• Rationale: Prevents pronation/supination which could displace fracture fragments
• Caution: Avoid full supination which increases compartment pressures

Elbow Fractures

• Position: Elbow flexed 90°, forearm in neutral rotation
• Immobilization: Above-elbow cast or posterior splint
• Rationale: Balances stability with prevention of flexion contractures
• Caution: Avoid hyperflexion (>90°) which increases risk of neurovascular compromise

Humeral Shaft Fractures

• Position: Elbow flexed 90°, neutral shoulder rotation
• Immobilization: U-slab/sugar-tong splint with collar and cuff
• Rationale: Allows gravity to assist with fracture alignment
• Caution: Avoid dependent positioning which may cause traction neuropathy

Proximal Humerus Fractures

• Position: Neutral rotation, slight abduction (15°)
• Immobilization: Shoulder immobilizer or sling
• Rationale: Minimizes displacement while allowing early pendulum exercises

Lower Limb Fracture Positions

Ankle Fractures

• Position: Ankle at 90° (neutral dorsiflexion), slight eversion
• Immobilization: Below-knee cast with three-point molding
• Rationale: Prevents equinus deformity and maintains reduction
• Caution: Avoid plantarflexion which can lead to equinus contracture

Tibial Shaft Fractures

• Position: Knee flexed 5-10°, ankle at 90°
• Immobilization: Long leg cast with knee slightly flexed
• Rationale: Prevents rotation and maintains length
• Caution: In severe trauma, temporary external fixation may be preferred over casting to allow soft tissue monitoring 2

Femoral Fractures

• Position: Slight knee flexion (15-20°)
• Immobilization: Typically requires surgical fixation rather than casting
• Alternative: Skeletal traction with knee in slight flexion if surgery delayed
• Rationale: Prevents quadriceps spasm and fracture displacement

Foot Fractures

• Position: Neutral ankle position, slight hindfoot eversion
• Immobilization: Below-knee cast or walking boot
• Rationale: Maintains arch and prevents deformity

Special Considerations

Neurovascular Monitoring

• Ensure regular neurovascular checks (circulation, sensation, movement)
• Cast should be split or bivalved if compartment syndrome is suspected
• Monitor for the 5 P's: Pain, Pallor, Paresthesia, Paralysis, Pulselessness 3

Severe/Open Fractures

• In cases of severe trauma or open fractures, temporary external fixation is often preferred over plaster to allow wound management and soft tissue monitoring 2, 4
• For femoral and tibial shaft fractures with severe trauma, temporary stabilization (external fixator or skeletal traction) is recommended before definitive fixation 2

Compartment Syndrome Prevention

• Avoid circumferential tight bandaging
• Split or bivalve casts in high-risk cases
• Elevate limb to heart level
• Avoid excessive flexion at joints which may compromise circulation

Cast Application Technique

• Use appropriate water temperature (<24°C) to prevent thermal burns
• Limit to 8 layers maximum to prevent excessive heat generation
• Ensure adequate padding over bony prominences
• Apply three-point molding for optimal fracture alignment 5

Pediatric Considerations

• Higher remodeling potential allows acceptance of greater initial deformity
• Prioritize removable casts and splints when possible
• Minimize follow-up imaging if it won't change management 2

Rehabilitation Considerations

• Early mobilization of non-immobilized joints
• Active finger/toe exercises to prevent stiffness and edema
• Positioning to prevent dependent edema (elevation)
• Progressive weight-bearing based on fracture stability and healing 6

Proper plaster positioning is crucial for preventing complications such as malunion, joint stiffness, and neurovascular compromise. The positions described above represent the optimal functional positions that balance fracture stability with preservation of function and prevention of complications.