How to cast a distal both bone forearm fracture?

Perfect Casting Technique for Distal Both Bone Forearm Fractures

For distal both bone forearm fractures, the optimal casting technique requires positioning the wrist in a manner that counteracts the direction of fracture angulation rather than focusing solely on cast index, as this significantly reduces the risk of secondary displacement. 1

Initial Assessment and Indications for Casting

Conservative management with immobilization is appropriate for:

• Fractures with less than 50% joint involvement
• Stable joint
• Minimal displacement (less than 10 degrees angulation) 2

Casting Technique

Materials and Preparation

• Long-arm cast materials
• Padding material
• Assistant for counter-traction

Step-by-Step Casting Procedure

1. Proper Positioning:

   • Position the wrist in a way that counteracts the direction of fracture angulation (this is more important than cast index for preventing secondary displacement) 1
   • For dorsally angulated fractures: position in slight flexion
   • For volar angulated fractures: position in slight extension

2. Application Technique:

   • Apply adequate padding, especially over bony prominences
   • Maintain the forearm in neutral rotation (not pronation or supination)
   • Extend the cast from metacarpal heads to just below the axilla
   • Ensure the elbow is at 90 degrees flexion
   • Mold the cast carefully around the fracture site while maintaining reduction

3. Cast Parameters:

   • While cast index (ratio of sagittal to coronal width) below 0.9 is traditionally recommended, proper wrist positioning is more critical 1
   • Ensure the cast is not too tight or too loose

Post-Casting Care

1. Initial Monitoring:

   • Observe for signs of compartment syndrome or neurovascular compromise
   • Schedule follow-up radiographs within 5-7 days to check for secondary displacement

2. Exercise Program:

   • Encourage early finger motion to prevent edema and stiffness 2
   • Implement active and passive range of motion exercises for uninvolved joints

3. Follow-up Protocol:

   • Regular assessment of wound healing and radiographic union 2
   • Schedule follow-up with new x-rays in 3 months 2
   • Begin weaning from the brace and implementing a home exercise program when appropriate 2

Potential Complications and Prevention

• Secondary Displacement: Position the wrist to counteract angulation forces rather than focusing solely on cast index 1
• Joint Stiffness: Encourage early finger motion and implement appropriate exercise programs 2
• Skin Breakdown: Provide extra padding over bony prominences, especially in diabetic patients 2
• Chronic Pain: Consider vitamin C supplementation to help prevent disproportionate pain 2

Special Considerations

• For unstable fractures or those with significant displacement, surgical intervention with open reduction and internal fixation (ORIF) may be necessary 2
• In pediatric patients, closed reduction and casting has significantly fewer complications (5%) compared to operative techniques (33-42%) 3
• For children 10 years or younger with less than 30 degrees post-casting angulation, full range of motion and minimal residual angulation can be expected 4

When to Consider Alternative Treatment

Consider surgical intervention when:

• Fracture is unstable despite proper casting
• Secondary displacement occurs
• Fracture involves more than 50% of the joint surface
• Angulation exceeds 10 degrees 2