Emergency and Urgent Care - Prevention of pressure ulcers under plaster casts, appliances and braces

What is a pressuer ulcer?

A pressure ulcer is damage that occurs on the skin and underlying tissues due to the lack of blood and oxygen supply.

Although not conclusive, the most common places for pressure ulcers to occur are over bony areas of the body like the heel, elbow, ankle, wrist and shoulder.

Causes of pressure ulcers

• Pressure – the weight of the body pressing down on the skin
• Appliance/splint too tight which leads to pressure being exerted on the skin
• Appliance/splint too loose which leads to rubbing of the skin If this pressure on the skin is not relieved, a wound called a pressure ulcer can develop under the splint, which can potentially become infected and seriously complicate your treatment

Warning signs

• Pain/burning
• Red patches over bony areas of fair skin
• Purple/black patches over bony areas of dark skin
• Blisters
• Your fingers or toes on the affected limb are numb or develop pins and needles
• Heat
• Swelling
• You are unable to move your fingers or toes on the affected limb
• Your fingers or toes on the affected limb become blue
• Your fingers or toes on the affected limb become swollen and the swelling does not reduce when you elevate your limb
• Your plaster, brace or appliance becomes loose, cracks, becomes soft or starts to rub
• The plaster cast has developed a smell
• You develop areas of localised pain of heat under the cast/ appliance/splint
• You feel that the inside of the cast/appliance/splint is wet or sticky

It is important to immediately report any of these signs or any other changes to your skin to the plaster room or the emergency department, as you may need an adjustment to your cast, appliance, or brace to ensure that any pressure is relieved.

How to reduce the risk of developing pressure ulcers

If possible, remove the splint daily and inspect the skin looking for:

• Purplish/bluish patches on darker skins
• Red patches on lighter skins that do not blanch (go white) following release of light finger pressure
• Swelling
• Blisters
• Shiny areas
• Dry patches or cracks
• Ensure the top and bottom of the cast does not rub or leave red marks on your skin
• Keep your arm or leg raised on a soft surface, such as a pillow, this will help any swelling to go down
• The position of the limb in the plaster cast/appliance/splint should be changed frequently
• Ensure all toes/fingers can move freely without rubbing
• Regularly change your whole-body position at least every two hours
• If you are in a leg cast and turning on your side, place a pillow in-between the knees to prevent the cast rubbing on the other leg
• Do not rest the leg in a plaster/appliance/splint on the heel for any length of time as this will put pressure on the heel
• Elevate your leg on a firm pillow allowing the heel section to float free

High risk patients

• Poor skin integrity/fragile skin
• Diabetes - Reduced sensation or the ability to feel pain
• Alcohol dependence - Reduced sensation or the ability to feel pain
• Peripheral arterial disease
• Wounds/eczema/skin lesions
• Previous pressure ulcers
• Medication – i.e.: steroids
• Learning disabilities
• Reduced mobility or movement
• Extremes of age
• Dementia
• The inability to communicate irregular skin sensation or pain
• Vulnerable bony prominences