Fracture and Cast Care
First, some concepts so that you understand what I have placed on your arm!
If you were seen in the emergency room with a recent fracture, you probably have a SPLINT on, not a CAST.
A splint is made of hard material, probably plaster, that is only on one side of your arm or finger. The soft material, probably white cotton cast padding and beige elastic knit material, goes all around your arm and is what you see when you look at it. Feel it: if the hard material is only on one side, it is a splint. This type of immobilization supports your arm or finger, but allows it to swell without restricting the blood flow. Generally, the splint will be changed to a cast after a few days to a few weeks, depending on the type of injury you have.
A cast is made of hard material, probably plaster or fiberglass, and the hard material goes all the way around your arm or finger. If you touch it and the outside material is hard and it goes all the way around your arm or finger, it is a cast. This gives more rigidity to the support of your arm than does a splint, but has limited ability to allow your arm or finger to swell.
Feel your "cast", and decide if it really is a cast or if it is a splint. Now let's go on to the more important things!
Living with a splint or cast
First, keep your arm elevated. If your arm is below the level of your heart, it will hurt more. Keep it up, at shoulder level or higher. Prop it up with a pillow when you are sitting or lying down, hold it up when you are standing. Don't use a sling, as this puts your arm below the level of your heart.
How long should you hold it up? If it hurts to put it down, you still need to keep it up! Don't get too frustrated, many people have learned to cope with this aggravation, and you will, too. It usually only needs to be up for two or three days.
It takes about 48 hours for the splint or cast material to fully dry and harden. Treat it gently.
Don't let the splint or cast get wet. The splint or cast material will soften and not harden again. In addition, the padding will not fully dry and your skin will get injured.
Don't scratch under the splint or cast. You may get a skin infection.
Don't pick at the cast padding. It will pull out from inside the splint or cast and then it will not be adequately padded.
Don't trim or alter the splint or cast. If an edge is uncomfortable, try padding it with Dr. Scholl's moleskin (foot care section of the drugstore) or some white medical tape. If it remains uncomfortable, please call the office (415-925-0501).
Fractures are painful injuries, so expect it to be somewhat uncomfortable. Resting your arm, elevation, and Tylenol are usually all that are needed. Prescription pain medication is rarely needed. If your hand or arm become too painful, please call the office.
It is possible that your hand or arm could swell inside the cast or splint, and it could become too tight. This is extremely rare, so rare in fact that I have never had a case of it in my practice. Keeping your arm elevated above the level of the heart will usually prevent this. If necessary (usually only the first one or two days) keep the arm above the level of your shoulder. Wearing a sling always puts the arm below the level of the heart, so slings are not usually used.
The best way to tell if the cast is too tight is if the cast feels too tight and you begin to notice progressive numbness (numbness that starts and gets worse) in the fingers. If you get progressive numbness, please call the office right away.
Be careful with the splint or cast. If it cracks, call the office.
Instructions After a Fracture
These are the instructions I normally give a patient when I see them in the ER for a fracture.
I have discussed with you what your fracture is, shown you the xrays, and discussed various treatment options. I will discuss these again with you when I see you in the office. For now, here are some instructions for the initial period of time and for a successful recovery!
1) Pain is usually one of a patient's first thoughts after a fracture: Is this going to hurt? How much is it going to hurt? I know that post-fracture pain is important to you and I want you to know that it is important to me, too. I have studied the post-fracture pain of my patients for several years and have worked out a system that has been highly satisfactory to the patients. If this box is checked I have given you a long-acting numbing shot as part of the treatment for your fracture. This means that part of your arm or hand may be profoundly numb for about 8 to 12 hours after treatment, and somewhat numb for longer. Do not let this alarm you. However, numbness that is other than a minor amount that develops after you leave the emergency room (or after treatment at any other location) is not normal and you should give me a call if it persists.
2) You should take aspirin or Motrin (as long as you can normally take these medications) every three to four hours, or the prescription medication Vioxx (if I gave you that) twice a day, starting as soon as you get home, and for one or two days thereafter. I recommend that you take this non-narcotic medication whether or not you hurt, since it is easier to stop a pain from starting than to stop it after it has started. Do not take these if your doctor has instructed you not to take these medications (eg, you are already on prescription blood thinners you should not take aspirin or Motrin; Vioxx is OK). Do not take Tylenol, since it is in the narcotic medication that I gave you (see below).
3) Most patients are also given a prescription for post-fracture pain medication that is a narcotic. This is usually Vicodin or Tylenol with codeine. (Please get it filled, even if you think that you will not need it. I would hate for you to have to send someone out in the middle of the night if your hand starts to hurt!) Please do not take this medication unless the aspirin, Motrin, or Vioxx is not sufficient. The chief side effect of the narcotics is constipation, and they have other side effects (drowsiness, addiction, etc.). Use the narcotic medication only if needed. Don't take it just because I gave it to you. Many patients find that the long-acting numbing shot, the non-narcotic medication, and elevation (see #5 below) are all they need. Take it only if you need it. If you truly need it, take it and don't be overly concerned. I just don't want you to take it unnecessarily. Use it only as directed on the bottle. This medication usually contains Tylenol, so please don't take Tylenol in addition to this medication.
4) If you need to take the narcotic medication, you should alternate the prescription-strength pain medication with the aspirin or Motrin. You can keep the same dosing schedule (eg, for the aspirin or Motrin, every three to four hours), just alternate the prescription and non-prescription medications. For example, if you are taking the Motrin every 4 hours and the prescription pain medication every 4 hours, you can alternate them, taking one every 2 hours, eg, Motrin at noon, prescription medication at 2, Motrin at 4, prescription medication at 6, etc. This gives you the best of both worlds. Try to stop the prescription medication as soon as you can, to avoid its side effects.
5) My patients tell me that elevating their arm above the level of their heart is more effective in relieving pain than any medication. Elevation also helps to prevent swelling, which will decrease your ability to move your fingers later on. Therefore, keep your arm elevated above your heart for two to three days after your fracture. If putting it up at shoulder level is not sufficient to help the pain, put it up higher (the "Statue of Liberty" position). I know that it is hard to keep your arm elevated once you fall asleep. Just do the best you can. A sling does not keep your hand above your heart, so I usually don't recommend one.
6) My patients also tell me that ice is the second most effective treatment for pain, again even stronger than the prescription pain medication.
7) You should have been instructed to call my office to make a follow-up appointment with me in ______days; if not, make it for about 10 days after your fracture. Call on the next weekday; do not wait until the day you need the appointment, or my schedule might be filled up!
8) Keep the splint or cast clean and dry. Use a plastic bag while showering.
9) Some swelling after a fracture is normal. A splint has plaster that only goes part of the way around your arm, the rest is a soft material, and the surface (the part you can see) is always a cloth material. A cast has plaster that goes all the way around your arm and the surface (the part you can see) is usually plaster. Feel your splint or cast and you can determine which it is. A splint has been placed if I think that there is much of a chance for swelling, as the splint can expand. A cast has been placed if I think that there is not much of a chance of swelling and I felt you needed more immobilization. Some swelling is normal. If you experience significant swelling that causes your hand to feel numb, you should call and discuss it with me. If you are worried, keep this in perspective: the occurrence of harmful swelling is very rare (I have not yet seen it in over 10 years in practice.)
10) Discoloration of your hand or arm is probably normal, as the blood from the fracture seeps through your tissues. This discoloration looks like a bruise in the early stages and a deep purple, then green, then finally yellow as the weeks go by. If you are unsure, check the pictures on the website at www.DavidLNelson.MD, under the section on casts and fractures. If you are still unsure, give me a call.
11) I have tried to cover the usual questions that my patients have asked me over the years with the usual answers. I cannot cover all questions and all situations. Use your judgement: complications are rare, and serious complications are very rare. If you need to call, try to do so during office hours, but I am always available to help you or discuss your recovery with you. Your recovery is important to both of us!
Before your appointment, be sure to go to the xray fileroom at Marin General Hospital, which is located on the second floor of the hospital, and get your xrays. Be sure to bring them to your appointment. You will not be able to be seen without the xrays.
I have tried to cover the usual questions that my patients have asked me over the years. I cannot cover all questions and all situations. Use your judgement: complications are rare, and serious complications are very rare.
If you would like to learn more about fracture healing, including pictures of what is going on inside your bone, click on Fractures in General.
Other Important Points
Please call the office on the next week day to arrange for a followup appointment. Don't delay calling until you need the appointment, because we will be sure to be busy. Call on the next week day! I usually want to see you within a week or so of the emergency room visit. Check the paperwork you got from the emergency room, it is written down there.
Pick up your xrays from the Radiology Department Fileroom, First Floor (one up from Ground Floor) at Marin General Hospital, and bring them to the office with you. If you forget to do this, I will have to send you back to get them, so make a note to remind yourself. (In the "old days", there was a delivery service, but now you are the "delivery service"! Thank managed care.)
