What are the proper cast care instructions after a fracture, including keeping it dry, daily skin inspection, limb elevation, pain management, and special precautions for patients with gastrointestinal ulcer disease, renal impairment, anticoagulation, or children?

Cast Care After Fracture

Proper cast care requires keeping the cast completely dry, elevating the limb above heart level for 48-72 hours, performing daily skin inspections around cast edges, and seeking immediate medical attention for uncontrolled pain, numbness, or signs of compartment syndrome.

Essential Cast Care Instructions

Keep the Cast Dry

• Never allow the cast to get wet, as moisture compromises structural integrity and increases risk of skin breakdown and infection 1
• Cover the cast with a waterproof barrier during bathing or showering 1
• Most unplanned cast changes (47%) occur due to wetness from patient non-adherence to instructions 1
• If the cast becomes wet, contact your healthcare provider immediately for evaluation and possible replacement 1

Limb Elevation and Swelling Management

• Elevate the casted limb above heart level for the first 48-72 hours to minimize swelling 2
• Continue elevation as needed if swelling persists beyond the initial period 2
• For upper extremity fractures, begin early finger motion immediately to prevent edema and stiffness 3
• For lower extremity casts, perform toe exercises to maintain circulation 2

Daily Skin Inspection

• Inspect skin around all cast edges daily for redness, irritation, or breakdown 4
• Check for foul odor emanating from the cast, which may indicate skin infection 4
• Monitor for any drainage visible on the cast exterior 4
• Never insert objects into the cast to scratch itching skin, as this can cause skin injury 4

Pain Management Considerations

Standard Pain Control

• Regular paracetamol (acetaminophen) should be administered routinely for baseline pain control 3
• Augment with carefully prescribed opioid analgesia as indicated for breakthrough pain 3
• Pain should progressively improve over the first few days after casting 4

Special Populations Requiring Modified Analgesia

Patients with gastrointestinal ulcer disease:

• Avoid NSAIDs due to increased bleeding risk 3
• Use paracetamol as first-line agent with opioids for breakthrough pain 3

Patients with renal impairment:

• Adjust opioid dosing based on creatinine clearance 3
• Avoid NSAIDs entirely due to nephrotoxicity risk 3

Patients on anticoagulation:

• Avoid NSAIDs due to increased bleeding risk when combined with anticoagulants 3
• Monitor closely for compartment syndrome, as anticoagulation may mask early signs 3

Pediatric patients:

• Use weight-based dosing for all analgesics 3
• Provide clear instructions to parents about acceptable pain levels versus warning signs 3

Critical Warning Signs Requiring Immediate Medical Attention

Compartment Syndrome Red Flags

• Uncontrolled pain that is disproportionate to the injury or not relieved by prescribed analgesics 4
• Progressive pain despite appropriate medication 4
• Numbness or tingling in fingers or toes 4
• Inability to move fingers or toes 4
• Pale, blue, or cold fingers/toes 4

Other Serious Complications

• Foul odor from the cast suggesting infection 4
• Fever developing after cast application 4
• Visible drainage on cast exterior 4
• Skin irritation progressing to open wounds at cast edges 1

Activity Modifications and Rehabilitation

During Immobilization

• Maximize use of removable splints when clinically appropriate to allow for skin inspection and hygiene 3
• For upper extremity casts, maintain shoulder, elbow, and finger range of motion in uncasted joints 3
• Avoid above-chest-level activities until fracture healing is evident 3

After Cast Removal

• Begin aggressive finger and hand motion immediately after upper extremity cast removal to prevent long-term stiffness 3
• Expect significant impairments immediately post-casting, including 40% deficit in forearm rotation and 50% reduction in wrist motion 5
• Refer to physical or occupational therapy for structured rehabilitation to prevent long-term disability 5

Common Pitfalls to Avoid

• Do not ignore escalating pain - this is the most important warning sign of compartment syndrome and requires immediate cast splitting or removal 4
• Do not assume all cast changes are due to poor technique - 80% of unplanned cast changes result from patient non-adherence rather than application errors 1
• Do not delay seeking care for wetness - wet casts lose structural integrity and increase infection risk significantly 1
• Overly aggressive physical therapy after cast removal may increase fixation failure risk in surgically managed fractures 3
• Do not neglect uncasted joints - immobilization of adjacent joints leads to unnecessary stiffness and prolonged recovery 3, 5