Cast Removal

Abstract

Cast removal is a routine yet critical procedure in pediatric orthopaedic care, requiring meticulous attention to safety and detail to prevent avoidable complications such as thermal injury, lacerations, and subsequent patient anxiety. This review provides a comprehensive overview of best practices as it relates to safe cast removal, highlighting techniques, equipment considerations, and common pitfalls. Cast saws remain the standard tool for cast removal; however, improper use can result in friction burns or skin lacerations, particularly in young patients with thinner soft-tissue envelopes. Strategies to mitigate these risks include regular cast saw blade maintenance, proper saw angulation, intermittent cutting techniques, cooling of the blade, and the use of protective padding. Emerging technologies such as cast spreaders, alternative cutting tools, and water-softenable casting materials may further improve safety profiles. Additionally, patient cooperation and comfort plays a crucial role in safe cast removal, creating a calming environment and using child-friendly communication is paramount. In rare cases, sedation can be considered to help safely remove a cast in a traumatized child. This review synthesizes current evidence on the biomechanics of cast saws, injury risk factors, and training recommendations to enhance safety during cast removal.

Key concepts: (1)Proper Cast Saw Technique - Intermittent cast saw application with a perpendicular saw angle minimizes heat generation and reduces the risk of thermal injury and soft tissue damage.(2)Adequate Padding Assessment - Ensuring at least two layers of cast padding and a stockinette before cast removal decreases the likelihood of skin lacerations or pressure injuries.(3)Patient Positioning and Cooperation - Stabilizing the limb and maintaining patient comfort during cast removal reduces movement-related errors and improves safety.(4)Use of Cast Spreaders - After initial saw cuts, cast spreaders should be employed to avoid excessive blade contact and potential injury.(5) Careful inspection of the cast saw prior to cast removal and regular blade replacement when dull helps prevent avoidable cast saw injuries.

Keywords: Cast burns; Cast padding; Cast saw; Cast spreader.

Figure 1

Cast removal supplies (pictured from left to right): water-soaked rolled gauze, cast splitter, cast saw blade key, bandage/safety scissors, spare cast saw blade, and cast saw.

Figure 2

Picture of used cast saw blade (left) with example of roughened edge at the 1’ o’clock position (highlighted in red) as compared to new cast saw blade (right).

Figure 3

Proper bracing technique pictured with the spare hand used to stabilize the cast. Note the cast saw is held perpendicular to the cast surface and gripped with an index finger used to help control depth of cast excursion toward the patient's skin.

Figure 4

Image of a cast saw cut from improper technique used during cast removal. It is critical to avoid dragging the cast saw blade along the skin to avoid skin tears.

Figure 5

Demonstration of appropriate use of wet rolled gauze/webril to expedite cast saw blade cooling. Frequent breaks should be taken between use of the cast saw to carefully feel the temperature of the cast saw blade and delay further use until the blade has returned to safe temperature.

Figure 6

Image of a cast saw burn from improper technique used during clubfoot cast removal. Ponseti casts are applied with only 1–2 layers of cotton role and thus may be at higher risk of cast saw injury. It is critical to take frequent breaks and feel the cast saw blade temperature before resuming cast saw use. Employing techniques like cast saw vacuums and cooling the cast saw blade with water or 70% isopropyl alcohol-soaked gauze/webril can reduce risk of injuries.