What is the technique for applying a fiberglass cast to a fractured right hand after confirming satisfactory closed reduction and intact neurovascular status?

Fiberglass Cast Application Technique for Fractured Right Hand

After confirming satisfactory closed reduction and intact neurovascular status, apply a short arm fiberglass cast and immediately initiate active finger motion exercises through complete range of motion to prevent stiffness. 1

Pre-Application Assessment

• Verify adequate closed reduction with post-reduction radiographs showing acceptable alignment 2
• Document intact neurovascular status including capillary refill, sensation, and motor function 2
• Ensure the hand is warm, pink, with capillary refill less than 3 seconds 2

Cast Application Technique

Positioning and Preparation

• Position the hand and wrist in the functional position: wrist in slight extension (approximately 10-20 degrees), metacarpophalangeal joints free to move 1
• Apply stockinette from fingertips to mid-forearm, leaving fingers completely free 1
• Place padding over bony prominences, particularly the ulnar styloid and distal radius 3

Fiberglass Application

• Use 2-3 layers of fiberglass casting material for adequate strength 3
• Mold the cast carefully during the setting phase to maintain reduction and prevent pressure points 3
• Ensure the cast extends from just below the elbow to the metacarpal heads, leaving all finger joints completely free 1
• Critical: The metacarpophalangeal (MCP) joints must remain completely mobile for immediate finger exercises 1

Immediate Post-Application Protocol

Mandatory Finger Motion Program

• Instruct the patient to begin active finger motion exercises immediately after cast application, moving through complete range of motion 1
• Emphasize that finger motion does not adversely affect adequately stabilized fractures 1
• Prescribe a home exercise program for finger motion during the entire immobilization period 1

This immediate finger mobilization is critical because finger stiffness is extremely difficult to treat after fracture healing and represents one of the most significant preventable complications. 1, 4

Patient Education on Complications

• Warn patients about signs requiring immediate return: increasing pain, numbness, tingling, color changes, or inability to move fingers 3
• Approximately 25% of patients experience some form of complication with fiberglass casts, most commonly skin complications and cast-related problems 3
• No severe complications (compartment syndrome, venous thromboembolism, or infection) occurred in a large audit of fiberglass casts when properly applied 3

Follow-Up Imaging Schedule

• Obtain repeat radiographs at approximately 3 weeks to monitor alignment 1
• Obtain final radiographs at time of immobilization cessation to confirm healing 1

Duration of Immobilization

• For adequately reduced distal radius fractures in adults, 4 weeks of immobilization produces outcomes similar to 6 weeks 5
• The mean Patient-Rated Wrist Evaluation (PRWE) score showed no clinically relevant difference between 4-week and 6-week immobilization periods 5

Common Pitfalls to Avoid

• Never immobilize the MCP joints—this is the single most important technical error to avoid 1
• Do not delay finger motion exercises; stiffness develops rapidly and is difficult to reverse 1, 4
• Avoid excessive padding that may allow fracture displacement within the cast 3
• Do not apply the cast too tightly, as post-reduction swelling can lead to compartment syndrome 3

Special Considerations

When Cast Alone May Be Insufficient

• Fractures with postreduction radial shortening greater than 3 mm, dorsal tilt greater than 10 degrees, or intra-articular displacement require surgical fixation rather than casting 2
• Articular surface involvement exceeding one-third, palmar displacement of distal fragment, or interfragmentary gap greater than 3 mm are indications for operative fixation 1

Competency Requirements

• Staff applying casts must be competent in proper technique, as complications can be avoided when casts are applied correctly and patients are well-informed 3
• Proper molding during the setting phase is essential to maintain reduction 3