on this segment we'll be placing a long leg cast first thing you want to do is we like to position them in a sitting position so that we use gravity in our favor this helps align any fracture so that it doesn't displace by moving them around so much typically you can do these recumbent if you'd like to but you also run the risk of making the patient very uncomfortable you get a lot more movement especially the tibia shaft fracture that you're trying to stabilize here we're bunching the stockinette you can also do two separate stockinettes in different sizes using a larger size on the thigh area one thing that you always want to do is you're always checking your alignment talking with the patient while you're doing this keeping them at ease that's very important as you slide the stockinette up just be smooth with it i like to try to stabilize the back of the heel as i apply this and make sure that you don't cut yourself short on the proximal or the distal ends you can tell he's being very cautious with this patient because he's probably a lot of pain patients tend to hold a little bit still on this application because it hurts every once in a while they'll start to rock back and you just keep talking to them keep working through it check the back popliteal area to make sure there's no wrinkles in it reposition make sure everything's staying vertical with gravity pulling it in the direction you want it to foot placement is essential here oftentimes if you have a very unstable mid shaft fracture of the tibia and fibula but you want to keep the foot in plantar flexion to avoid any mild alignment such as reek or bottom a lot of times you take it as the patient will allow you in terms of 90 degrees versus you know 15 to 20 degrees in plantar flexion patting the heel on a long leg cast is essential a lot of patients will rest that as they sleep or in their recovery stage oftentimes that will cause some severe blistering for some reason pediatrics are notorious for this you'll see that we put adequate padding on the hill and work just to lead a proximal in this every once in a while you have a fumble where you drop your padding you can easily just rip it off and get a new roll and start patting it out whatever works best for you we're going to start out as if we're doing a short leg cast and this way when we bring the patient up onto the table it will be an easier transition that's what our main goal is is to establish a stable environment here with the short leg cast and work your way up once again constantly checking your patient make sure that they're maintaining that position that you want them to apply the cast so applying your casseroles you as a cast technician will learn what you fill the best with in terms of the size three inch versus four inch personally i like three inch for the distal end it gives me a little bit more contour around the heel because that is always a spot that causes wrinkles and the four inch seems to be just too bulky for me at this point you'll learn what you like the best and what works for you obviously you'll kind of gauge that off the size of the patient wrapping around the hill you just do it evenly and just let it flow oftentimes if you fight this it actually will cause wrinkles in the anterior part of the foot so just go with the flow and if you have to back track over it a couple times that's okay because strength in that area is imperative to keep it from indenting in on the hill you'll notice here lance had two separate rolls of cast material ready to go so he dropped them both in before he started and drained the water out of him and then set the one close by so as soon as he got done with the first roll he picked up the second roll and was able to just continue going at this point just focus on adequate strength in the lower leg just treat it like you would a lower leg you want to get good three to four layers here so that it is strong and once again reposition check for alignment always go hip knee first web space at this point if you have to apply any valgus or varus molding this is a good time to do it also check the back side so you don't have any wrinkles in the achilles area positioning will always be dependent upon your provider always go with their instructions and all your positioning for these types of casts and don't forget to check the x-rays you always need to view the x-rays before you apply the cast so you know exactly what you're treating oftentimes people are not in a very good condition often they're in pain sometimes they get nauseous at people who vomit who go into muscle spasms and you have to just be patient and talk them through it and do your best to stabilize and hold the extremity while they go through their situations we'll move the patient up onto the table and begin our proximal portion of this longley cast once you get them comfortably set on the table this is where you can have somebody come help you and help maintain the proper position you mainly want to get that knee flexed just a little bit there's a whole bunch of different degrees that you can do it at we prefer right around 30 to 40 degrees and that just gives them enough flexion to be able to get in and out of a vehicle to get in and out of bed to be able to transition and then also to be able to keep their foot and their toe off the ground as they are on crutches and moving around you'll notice the extra padding on top of the kneecap a little extra padding on there for bony prominence then as you work up to the thigh you want to make certain that you have plenty of padding up here as you roll it back this is an area that can irritate the patient consistently while they sit while they lie down whatever it might be if you don't pay enough attention and have enough padding at the very proximal end of this it's always a good idea prior to putting a cast like this on to explain to the patient beforehand what the process will be and what you'll be doing so the patient isn't uncomfortable as you're pulling the stockinette up and padding up near the growing area you'll notice right here that we're focusing on the first web space patella and also the femoral head and that's the alignment that you try to achieve as you apply this long leg cast and as you can tell there the person out on the distal end holding that lower extremity has a perfect line to line that up so it would be their job to keep an eye on that alignment the whole time the other person is casting as you overlap an existing cast it's always good to capture as much of the distal end as you can i have seen in my own experience and other casts that have been applied that if you don't overlap that enough that it'll actually crack and twist apart at that junction so capture it at the distal end and then work your way up from there see as you can see there he started at least halfway through the tibia to be able to have that top layer adhere to the bottom fiberglass that's already hardened before we move the patient so now it's going to adhere to that very well and it won't break down you'll have a less of a chance of getting wrinkles in that popliteal fossa we talk about the distal end being rigid enough that the patient now gains a little bit of trust in you as a cast technician that you're not going to hurt them they've become a lot more comfortable with that lower distal end of the cast set up enough that they're not moving around and they tend to relax at this point which makes it a little bit easier for the leg holder so that they can align that toe patella and femoral head you work your way up to the proximal end you get a good two to three layers around here to keep it nice and rigid one thing that i like to point out is that you want that proximal end to be pretty rigid before you pull your stockinette back if you get a little bit ahead of yourself and that cast has not cured as you pull the stockinette back it oftentimes will wrinkle and that's something you don't see until you take your cast off so learn from your mistakes when you take a cast off evaluate the ends evaluate everything and you can see where the weak spots are where you might need to strengthen up for the next time again here just showing the proper way of molding person out on the distal end again is maintaining that alignment and the person on the proximal end is giving just a perfect supracondylar mold right there on the distal end of the femur to mold the patella and to keep it from pivoting or shifting at all up there on the proximal end that mold is is very important as you're all aware after two to three weeks in a cast you'll experience a great amount of atrophy and by molding it it helps to keep that leg stable so that you don't get rotation on it you can always tell an orthopedic cast so practice that as you're looking around and just seeing different casts come into your clinic and or wherever you're working at but you can tell that they've visited an orthopedic clinic if they've got that really good mold on it and it's not a cylinder cast if they have that atrophy that cast up there on that proximal end is just going to have a big gap you'll see gaps up to two inches where that thing's just pivoting and shifting and anytime you create movement inside the cast you're gonna get abrasions on your skin because there's movement and they're gonna move it and it's gonna cause abrasions and it's gonna cause big problems take a little caution in rolling that back you want to pull it snug run your fingers across there to make sure there's nothing in terms of the stockinette that would be wrinkled underneath this is kind of what distinguishes you from other cast applicators is that you will have a really nice and and it shows that you're concerned about the welfare of your patient too you can drop in however many rolls you think you'll need to finish out the cast one thing we like to do is get a couple rolls you know fully inundated with the water and start your application you actually want this to set up a little bit faster so if you give it a few extra squeezes get that water out here's another instance where you can decide on your own your best judgment what size of cast material you will use to finish casts on a long leg you can get away with three or four inch because now you've got a rigid surface underneath you can pull a lot harder and you can pull the edges out one thing about your overlapping as you start to rub this sometimes it doesn't matter how hard you rub it and try to get it as smooth as you can there's always going to be some ridges with the aid of a person holding that cast you can get a little aggressive and rub those ridges in so that they are a lot smoother heard of some providers and cast technicians using lotion and they'll actually put lotion on there and rub it down really good and smooth out all the edges as you apply the last portion of the cast is a good time to evaluate the strength of the heel if you have to do a couple passes over that to strengthen it this is a good time to do it make sure you catch those last little portions of it so you don't have any white smiley faces on the back of the knee while they walk out you'll find a lot of times that you are your worst critic that's a good thing i put a cast on there's so many times i look at it and say i could have done better it all comes down to the nature of the fracture how painful the patient is and that will determine you know how fast you need to work and how careful you need to be make sure you continue to rub that last edge we don't like factory edges we always cut those off make sure you rub it down really good so it doesn't peel back on you we saturated the ace bandages in water ring the water out and lay this on your cast material while it's still pliable if you put it on dry it'll stick to that resin on the cast material and then you're peeling it off you can really crank on it and it'll help lay your edges down so they don't come back up and actually gives it a really nice looking finish so let that set just a few minutes and once again we're just showing you how well this is aligned and also made sure that the toes are free from impingement this is probably one of the more technical lower extremity casts one of the reasons is because you're dealing with someone a who is in pain and b who may have a very displaced fracture as you're aware at some point we can even discuss wedging casts and we do a lot of that we'll apply it let it set up bring them back a week later and apply a wedge if we need to so remember as you're cutting lower extremity casts off you want to be cautious of the medial and lateral malleolus so before you cut kind of eye where they are and be cautious that you cut around those because those are prominent areas on the cast where he'll hit now we can't over emphasize the fact of bouncing your saw blade do not hold it in one spot that's what generates the heat do it's always good practice to feel your cast saw blade on something like a long leg cast we're going to be cutting quite often when a patient tells you that you're burning them i've made it a practice to never be so cavalier to say this saw doesn't cut people the minute you say that you may nick them it may get hot and they've just lost their trust in you so if they do complain stop touch the blade make sure it's not hot and at that point they can relax if you are cutting a damp cast one that hasn't quite cured you will tend to heat that blade up and they will fill that heat immediately listen to them you know if they tell you it's uncomfortable stop while cutting this off you can tell that i cut around the distal end of that stockinette that's the piece of the stockinette that was folded back so all you have to do is cut around the top part of that same thing on the proximal end and then you can peel that shell right off from the cast padding and then you just cut right up the cast padding and stalking it and lift third leg right out when you're done examine your cast look for those flaws or imperfections and so that you can improve on your next one you'll learn a lot from your own mistakes you