Nonoperative treatment - Below-knee cast

Most tibial shaft fractures require initial management with a long leg cast.

A below-knee cast (or short leg splint or brace) may provide sufficient support for stable diaphyseal tibial and fibular injuries.

Tibial fractures managed with a short leg cast require close radiological follow-up.

A short leg cast can also be used following surgical fixation in the early postoperative period.

• Pressure sores
• Skin irritation
• Loss of reduction
• Compartment syndrome
• Thermal burns (avoid using hot water)

Read the additional material on preoperative preparation.

• Tubular bandage (stockinette) of appropriate size
• Cast padding
• Felt
• Casting material: synthetic, plaster of Paris, or a combination of both
• Water

The water temperature should ideally be between 22° and 25° C.

Place the patient in a supine position with a bolster under the knee to keep it flexed.

An assistant also supports the leg to maintain knee flexion.

The cast extends from just below the knee to the base of the toes.

Apply a tubular bandage and cut it slightly longer than the length of the final cast.

The assistant holds the toes, not the stockinette, with the ankle in a neutral position.

Add thick felt or additional padding at the free edges of the cast and prominent areas (eg, tibial crest, malleoli, and heel) to prevent pressure sores.

Apply cast padding without creases, overlapping each layer by 50%.

It should be appreciated that, when more padding is applied, there will be less support at the injury site.

Apply the first layer of cast material and overlap each layer by 50%.

Avoid sharp edges at the ends of the cast.

Apply further layers of cast material to produce sufficient stability.

Avoid pressure over the fibular head and neck by adding sufficient padding and shortening the cast to prevent injury to the peroneal nerve.

Fold the tubular bandage and padding over the edges of the cast before applying the final layer of casting material.

Ensure that all toes are visible for vascular assessment.

A circumferential cast may be split to accommodate swelling or converted to a removable device to facilitate wound care in open fractures and injuries with significant soft-tissue involvement.

After cast application, check the fracture configuration with x-rays in both planes.

Confirm normal toe color and capillary refill at the end of cast application.

Parents/carers should understand the following precautions and instructions:

• Elevate the foot to the level of the heart to avoid swelling
• Check daily for swelling, discoloration, and impaired toe circulation (any of which should be reported immediately)
• Urgently report signs suggesting skin irritation ulceration, and cast soiling
• Make sure the cast padding remains dry and avoid inserting anything between the cast and skin

Non-weight-bearing or touch weight-bearing is encouraged for unstable injuries.

Older children may be able to use crutches or a walker.

Younger children may require a period of bed rest followed by mobilization in a wheelchair.

Routine pain medication is prescribed for 3–5 days after injury if required.

The patient should be examined frequently to exclude neurovascular compromise or evolving compartment syndrome.

The first clinical and radiological follow-up is usually undertaken 1–2 weeks after injury to confirm fracture position.

A radiograph to evaluate bone healing should be taken after about 4 weeks. When clinical and radiological signs indicate that the fracture no longer needs external support, the cast can be removed.

After cast removal, graduated weight-bearing is usually possible.

Patients are encouraged to start range-of-motion exercises. Physiotherapy supervision may be necessary in some cases but is not mandatory.

Activities that involve running and jumping are not recommended until full recovery of local symptoms.

Leg length should be evaluated up to 2 years following injury due to the effect of growth stimulation.