Nursing Field Notes / Musculoskeletal · Fracture & Trauma Care Series · Page 4 of 4
Cast Care 🦿
Living With a Cast — Watching For Compartment Syndrome
NG-063MusculoskeletalADHD-friendly visual edition
A cast protects a healing bone — but a cast can also become the injury if swelling inside it cuts off blood flow. This page teaches the patient (and you) how to live with a cast day to day, and how to run the same neurovascular check as the 6 P's from the Fracture page (NG-056) every single time — because the earliest sign of compartment syndrome is pain that elevation and pain medicine don't touch.
🚨 Pain that won't quitUnrelieved by elevation/analgesia + worse with passive stretch = compartment syndrome red flag.
🖐️ PMSC every checkPulses · Movement · Sensation · Color/temp — the cast version of the 6 P's.
💧 Clean, dry, elevatedBag it for showers, elevate above the heart for the first 48 hours.
❌ Nothing goes inside the castNo objects for itching — cool hair dryer only.
🚨
COMPLICATIONS
STEP 1 · WHAT CAN GO WRONG
A cast can hide swelling from view — which is exactly why the assessment matters more than what you can see.
🚨 Compartment syndrome — the emergency this whole page is built around
Compartment syndrome is an extremely painful condition that happens when pressure within the muscle compartments builds to dangerous levels — cutting off blood flow and oxygen and, left untreated, resulting in permanent tissue death.
🧠 "A cast doesn't stretch — but swelling doesn't stop." Once compartment pressure exceeds vessel pressure, the limb can lose blood flow and oxygen even though pulses may still be felt early on — don't wait for pulselessness.
🚨 Key sign #1: Pain
😖 Unrelieved with opioids — even morphine doesn't touch it
📈 Not resolving with medication or elevation
🖐️ Extreme pain with passive movement — pain when someone else stretches the fingers/toes
SAUNDERS Client reports severe, deep, unrelenting pain and pain as the nurse assesses finger movement. What condition?
Answer: compartment syndrome — pain out of proportion to injury, worse with passive stretch.
⚠️ Key sign #2: Paresthesia
⚡ Tingling, burning, numbness
🖐️ Trouble moving or extending fingers/toes — described as "great difficulty"
KAPLAN A nurse is assessing a client with a short leg cast for compartment syndrome. Which finding matches?
Answer: pain that increases with passive movement.
🌡️ Infection — the other cast complication
Watch for a "hot spot" on the cast — a localized area that feels hot, plus a foul odor coming from the cast. Both point to infection underneath, not just normal healing warmth.
KAPLAN Three hours after arriving on the orthopedic unit, a client reports a hot feeling under the cast. First action?
Answer: assess circulation in the casted extremity and change the client's position.
🧠 "Hot + foul smell = infection; cold + pale = compartment syndrome." Two different temperature clues point to two different emergencies — don't mix them up.
🖐️
ASSESS
STEP 2 · PMSC NEURO CHECK
This is the 6 P's from NG-056, re-packaged as the bedside "PMSC" check you run on every casted limb.
🖐️ PMSC — Pulses · Movement · Sensation · Color/temp
🧠 PMSC is the cast-specific shorthand for the 6 P's (see NG-056 for the full definitions of pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia). Any abnormal finding — even just one — gets reported.
✅ What normal looks like
💓 Pulses present, not pulseless
🖐️ Can move/grip fingers or wiggle toes
⚡ No tingling or numbness
⏱️ Capillary refill under3 seconds
🎨 Skin color normal, not pale
🌡️ Extremity warm, not cold or cool
🧠 "NOT" is the operative word for every line above — the nurse is ruling OUT compromise, every single check.
🚨 When any of these appear — notify HCP immediately
❌ Pulselessness
❌ Numbness, tingling
❌ Cold, pale foot/hand
❌ Swelling that keeps increasing
❌ Pain unrelieved by elevation or analgesia
SAUNDERS A plaster cast is placed on the lower extremity. Which instructions should be given to the client?
Answer: notify the HCP immediately for numbness, swelling, or if the foot becomes cold and pale; assess capillary refill, temperature, color, and amount of pain.
🩹
TEACH
STEP 3 · LIVING WITH THE CAST
Keep it dry, keep it up, keep it empty of objects — and report pain that won't back down.
🩹 Cast care — the daily rules
1
Clean & dry — NEVER wet. Cover the cast with a plastic bag for bathing/showers.
2
Elevate above the heart for the first 48 hours to limit swelling; continue elevating and icing as needed after.
3
Itch under the cast? Use a hair dryer on a cool setting — never insert an object.
4
Take it easy — no bearing weight on a plaster cast, no resting it on hard surfaces or letting fingers indent it while it's still setting.
🧠 "Bag it, prop it, blow it (cool), never poke it." Four rules, one cast — bathing, elevation, itching, and weight-bearing all covered.
❌ Never do this to a cast
🪥NO objects insertedcoat hangers, pencils
💧NO getting it wetplaster especially
🏋️NO weight-bearingon a plaster cast
🪵NO hard surfaceswhile setting
👉NO finger indentationswhile damp
🧠 An itch feels urgent — an infected scratch wound under a cast is worse. Cool hair dryer only.
⏱️ Drying time — plaster needs patience
🧠 Handle a fresh plaster cast with open palms, not fingertips — fingertip pressure while it's still setting leaves indentations that can press on skin once hard.
⚔️ Normal cast pain vs compartment syndrome — tell them apart
Expected post-fracture/cast pain
🚨 Compartment syndrome
Improves with elevation, ice, and scheduled analgesia
Not relieved by elevation or analgesia — even opioids
Worse with active movement of the limb
Worse with passive stretch — someone else moving the fingers/toes
Gradually improves over days
Pain that keeps climbing
Sensation, pulses, color all normal
Tingling/numbness, cold or pale skin may accompany it
🧠 The single red-flag phrase to remember: pain unrelieved by elevation and analgesia is not "a bad day" — it's compartment syndrome until proven otherwise. Notify the HCP immediately.
⚡
QUICK RECALL
SAY IT OUT LOUD
🚨 Pain unrelievedby elevation/analgesia = compartment syndrome red flag
🖐️ PMSCPulses · Movement · Sensation · Color/temp — the cast's 6 P's check
💧 Keep it drybag it for bathing; never insert objects for itching
⬆️ Elevate 48 hrsabove the heart to control swelling
🎯 Cover & check — 4 rapid-fire questions
Q1: What is the earliest, most reliable red flag for compartment syndrome?
Pain that is unrelieved by elevation and analgesia, especially pain with passive stretch of the fingers/toes.
Q2: What does PMSC stand for, and why is it done on a casted limb?
Pulses, Movement, Sensation, Color/temperature — the bedside version of the 6 P's used to catch neurovascular compromise early.
Q3: How should a patient shower with a plaster cast?
Cover the cast completely with a plastic bag — plaster casts must stay clean and dry, never wet.
Q4: The patient's cast itches. What's the safe teaching?
Use a hair dryer on a cool setting blown into the cast — never insert an object like a coat hanger or pencil.