What is a sample plan of care for a patient with a leg cast?

Plan of Care for Patient with Leg Cast

A comprehensive leg cast care plan should prioritize early mobilization with appropriate weight-bearing restrictions, aggressive finger/toe exercises to prevent stiffness, VTE prophylaxis, pain management with multimodal analgesia, and regular monitoring for cast-related complications including compartment syndrome.

Immediate Post-Cast Application Care

Neurovascular Monitoring

• Perform serial neurovascular assessments to detect early signs of compartment syndrome, which is particularly associated with tibia fractures and requires prompt recognition in all patients with leg casts 1
• Monitor for the "5 P's": pain (especially pain out of proportion or with passive stretch), pallor, paresthesias, pulselessness, and paralysis 1
• Assess capillary refill, sensation, and motor function at regular intervals (every 2-4 hours initially, then every 8 hours once stable)

Elevation and Edema Control

• Elevate the casted extremity above heart level for the first 48-72 hours to minimize swelling 2
• Apply ice to the cast (over a protective barrier) for 20-minute intervals during the first 48 hours 2
• Instruct patient to avoid dependent positioning of the leg for prolonged periods

Mobilization and Weight-Bearing

Weight-Bearing Status

• Determine weight-bearing status based on fracture stability and location - most stable fractures can tolerate weight-bearing as tolerated, while unstable fractures may require non-weight-bearing or partial weight-bearing 3
• For patients requiring reduced weight-bearing, provide bilateral crutches, walker, or rolling crutch walker to reduce pressure on the affected limb and prevent musculoskeletal complications in the contralateral limb 4
• Consider a shoe raise for the contralateral limb to minimize acquired limb-length discrepancy when wearing the cast 4

Early Range of Motion

• Begin aggressive toe exercises immediately after cast application to prevent edema and stiffness - this is essential and should not be delayed 4, 5
• Instruct patient to perform active range of motion of all non-immobilized joints (toes, hip, knee if not casted) multiple times daily 4
• Emphasize that early finger and toe motion is crucial to facilitate the best possible outcomes 5

Venous Thromboembolism Prophylaxis

Risk Assessment and Prevention

• Recognize that cast immobilization increases VTE risk significantly, with incidence ranging from 4.3% to 40% without prophylaxis 5
• Consider pharmacological VTE prophylaxis for patients at elevated risk (prolonged immobilization, history of VTE, obesity, malignancy, advanced age) - this can reduce VTE risk from 17.1% to 9.6% 5
• At minimum, provide mechanical prophylaxis with ankle pumps and toe exercises 5
• Educate patients on signs of deep vein thrombosis (calf pain, swelling, warmth) and pulmonary embolism (chest pain, shortness of breath)

Pain Management

Multimodal Analgesia Approach

• Utilize multimodal analgesia with the lowest effective dose of immediate-release opioids for the shortest period possible 2
• First-line: Acetaminophen 650-1000 mg every 6 hours (maximum 4 grams daily) 2, 6
• Add NSAIDs if not contraindicated: Consider diflunisal 1000 mg initially, then 500 mg twice daily, which provides effective analgesia with fewer side effects than acetaminophen with codeine 7
• Reserve opioids for breakthrough pain only, prescribing the minimum quantity needed (typically 3-7 days supply) 2

Non-Pharmacological Strategies

• Apply ice over the cast for 20-minute intervals 2
• Maintain elevation above heart level 2
• Consider transcutaneous electrical nerve stimulation (TENS) for additional pain control 2
• Implement anxiety reduction strategies such as aromatherapy if indicated 2

Cast Care and Monitoring

Patient Education

• Instruct patient to keep cast dry - provide waterproof cast cover for bathing
• Warn against inserting objects inside the cast to scratch, which can cause skin breakdown
• Advise patient to report immediately: increasing pain, numbness, tingling, color changes, foul odor from cast, or fever
• Educate about signs of cast complications requiring urgent evaluation

Follow-Up Schedule

• Schedule radiographic follow-up at 1-2 weeks post-casting to monitor fracture alignment and ensure no loss of reduction 5
• Plan for cast removal based on fracture type: typically 3-6 weeks for metatarsal shaft fractures, 4-6 weeks for tarsal fractures 3
• Arrange physical therapy referral for post-immobilization rehabilitation to address expected muscle weakness and joint stiffness 4

Rehabilitation Planning

Post-Immobilization Recovery

• Anticipate muscle weakness, atrophy, and joint stiffness following cast removal - these are expected complications of prolonged immobilization 4
• Initiate aggressive range-of-motion exercises immediately upon cast removal 4
• Progress to weight-bearing impact exercise and/or resistance training to restore function 8
• Continue rehabilitation until patient regains pre-injury level of mobility and independence 4

Special Considerations

High-Risk Populations

• Patients with diabetes require particular attention to skin integrity and wound development under the cast 4
• Elderly patients benefit from orthogeriatric comanagement to optimize outcomes and reduce complications 4, 8
• Patients on chronic opioids at presentation should have prescribing limited to one prescriber 2

Psychosocial Impact

• Recognize that prolonged immobilization can negatively impact psychological health, physical health, and socioeconomic well-being due to increased risk of social isolation and loss of work 4
• Connect patients to psychosocial interventions as indicated 2
• Provide realistic expectations about recovery timeline and functional outcomes