What is a suitable alternative to casting acetate for immobilization in patients, including pediatric and geriatric populations, with various fracture types and medical histories?

Suitable Alternatives to Casting Acetate for Immobilization

Fiberglass casts with waterproof liners represent the primary alternative to traditional casting acetate, offering superior patient satisfaction, water resistance, and comparable fracture stability across pediatric and adult populations. 1, 2

Primary Alternative: Fiberglass Casting Systems

Material Properties and Application

• Fiberglass casts activated by water (such as Scotchcast™) provide a lightweight, strong, durable, and water-resistant alternative that is easy to apply and well-tolerated by patients 3
• Fiberglass materials demonstrate excellent structural integrity without causing severe complications like compartment syndrome, venous thromboembolism, or infection in patients with uncomplicated extremity fractures 4
• The complication rate with properly applied fiberglass casts is approximately 25%, primarily consisting of minor skin complications and cast-related problems rather than serious adverse events 4

Waterproof Cast Liner Options

• Waterproof cast liners (Wet or Dry® or Delta Dry®) combined with fiberglass casting allow patients to bathe, swim, and receive hydrotherapy while maintaining adequate immobilization 5, 2
• Among 337 patients using waterproof liners, odor, itching, and drying difficulties were minimal, with minor skin complications occurring in only 5.9% of cases 5
• Wet or Dry® liners demonstrate superior water resistance and odor control, while Delta Dry® liners offer easier application and removal by technicians 2

Alternative Immobilization Strategies by Clinical Scenario

Pediatric Distal Radius Fractures

• Braces or splints effectively manage buckle and minimally displaced distal radius fractures, avoiding traditional cast complications 1
• For Salter-Harris II fractures, well-molded casts with cast index <0.8 at the fracture site and three-point molding prevent loss of reduction while maintaining full finger range of motion 6
• Active finger motion should never be restricted during treatment, as this increases stiffness risk without improving fracture stability 6

Pediatric Femur Fractures

• Single-leg spica casts or flexible intramedullary nails avoid complications associated with double-leg spica casts 1
• Pavlik harness provides effective immobilization in infants with femur fractures 1

Toddler's Fractures and Stable Foot/Ankle Injuries

• Braces or splints serve as effective alternatives to traditional casts for toddler's fractures and stable foot/ankle fractures 1

Distal Phalanx Fractures

• Protective splinting for approximately 3 weeks with immediate active finger motion exercises prevents stiffness while allowing adequate healing 7
• Radiographic follow-up at 3 weeks and at immobilization removal confirms healing without requiring circumferential casting 7

Distal Radius Fractures in Elderly Patients

• Cast immobilization remains appropriate for distal radius fractures after low-energy falls in elderly populations, though operative methods (locking plates, Kirschner wires, external fixation) may be considered based on fracture characteristics 8

Critical Implementation Considerations

Cast Application Technique

• Proper cast application by competent staff is crucial—when applied correctly with adequate patient education, complications can be avoided 4
• For pediatric radius fractures, the cast must never obstruct full finger range of motion, and finger motion exercises should begin immediately 6

Monitoring Requirements

• Radiographic follow-up at approximately 1 week post-reduction detects early loss of reduction, with continued monitoring at 3 weeks and at cast removal 6
• Monitor for immobilization-related complications including skin irritation and muscle atrophy, which occur in approximately 14.7% of cases 7

Cost Considerations

• While fiberglass systems cost more than traditional plaster casts, the expense is not prohibitive and is offset by reduced complications and improved patient satisfaction 3
• Waterproof liners add minimal cost while significantly improving quality of life by allowing normal bathing and swimming activities 5

Common Pitfalls to Avoid

• Avoid restricting finger motion during forearm or wrist immobilization, as this increases stiffness without improving fracture stability 6
• Do not use traditional casting when waterproof alternatives are available for stable fractures, as patient satisfaction is significantly higher with waterproof systems 5, 2
• Ensure cast index remains <0.8 at fracture sites in pediatric patients to prevent loss of reduction 6
• Recognize that allergic reactions, liner bulkiness, and difficulties with cast application/removal have not proven problematic with modern waterproof systems 5