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Serial casting – lower limb fact sheet

Serial casting – lower limb

Serial casting is a common procedure used to stretch and lengthen muscles. Children may have shortened muscles due to limited movement, muscle tightness or muscle stiffness called spasticity. Casting is a common treatment for the management of children who walk on their toes. For children with spasticity, serial casting may be used after Botulinum Toxin injections.

How it works

The prolonged stretch provided by the cast may:

  • increase the length of the muscle
  • reduce the spasticity in the muscle
  • improve your child’s walking pattern
  • improve tolerance of ankle foot orthoses

At QPRS we use two different types of casting material: soft cast and hard cast, as well as a variety of under-wrapping materials. Your physiotherapist will discuss with you which is the most appropriate for your child.

Serial casting for the calf muscle involves placing one or both of your child’s ankles into a cast. Each cast remains in place for approximately one week and is then changed at weekly intervals. With each cast change, the stretch on the calf muscle is gradually increased until the desired length of the muscle is achieved. There is no set time as to how many weeks your child will require casting but your physiotherapist will be able to indicate an approximate time period at the beginning of your child’s cast series. Most cast series are completed within three weeks but if the muscle is very stiff or tight, it may take longer.

When planning a cast series, it is important to discuss your child’s program with your physiotherapist.

A cast series might need to be delayed due to events such as swimming carnivals and family holidays. Aside from getting the cast wet, your child will be able to participate in their normal daily activities and this should be encouraged.

Important things to check

Discomfort

Once the cast is in place, your child shouldn’t find it painful but may feel some mild discomfort or cramping due to stretching. This occurs most frequently during the first two days and can often be settled with children’s paracetamol or ibuprofen. If you are concerned about the discomfort, contact your physiotherapist immediately or remove the cast as per instructions below (depends on type of cast).

Circulation

It is important to regularly check your child’s circulation to their toes:

  • Press the tips of the toes. They should turn white and then return to a pink colour within two seconds.
  • If the toes remain white, become blue or are unusually cold or swollen, the cast may be too tight and the circulation to your child’s toes may be affected. Discuss this with your child’s physiotherapist immediately or remove the cast if you are concerned.
  • The physiotherapist may suggest the casts be removed. If the cast is made of a soft cast material you may remove the cast yourself. If it is outside of working hours and you cannot contact your child’s physiotherapist, remove the cast and call them as soon as possible. If the cast is made of a hard cast material please report to your local hospital to have the casts removed.

Sensation

If your child complains of numbness, tingling or ‘pins and needles’ at any stage during casting, discuss this with your child’s physiotherapist as soon as possible. The cast may be causing pressure on a nerve and may need to be removed.

Pain

If your child persistently complains of localised pain, particularly around the ankle or heel bones, there may be a blister or pressure sore developing. Please contact your physiotherapist if this occurs or remove the cast if you have any concerns.

Dampness

It is common for children to sweat excessively in their casts especially during warmer weather.

This can cause moist, white skin but it is not a problem unless it is painful, which is uncommon. Contact your child’s physiotherapist if it becomes a problem and please let them know for any future casts so it can be prevented from happening again.

Itchiness

Itchiness under the cast can be a common issue. The best way to relieve the itchiness is to gently knock on the cast. Do not stick anything down the cast as the skin is very fragile and may tear. Very occasionally itchiness may be due to an allergic reaction to one of the casting materials. If your child has sensitive skin and you suspect this may be the case please contact your child’s physiotherapist to discuss this with them as the cast may need to be removed.

Caring for your casts

To maximise your child’s comfort and safety during the cast series please follow these recommendations:

  • Do not immerse the cast in water, even if covered. It may be easier to sponge bath smaller children.
  • Avoid sand pits or sand at the beach, loose bark (common in playgrounds), dirt or gravel. These can become very irritating if they get inside the cast and can cause pressure sores to develop.
  • Avoid wet grass (slip on shoes or plaster shoes may be helpful during wet weather).
  • Avoid sticking objects inside the casts even if your child complains of itchiness (see above). These can tear the skin or can get stuck inside the cast and create pressure.

Removing the casts

  • Soft cast: If your child’s cast is made with a soft cast material you may remove the cast at home by carefully unwrapping it. Follow your child’s physiotherapist’s instructions regarding when the cast should be removed and what precautions to take following removal.
  • Hard cast: If the cast is made of hard material it will need to be removed with a special cast removal saw. Do not try to remove the cast yourself. If the cast requires early removal, contact your physiotherapist or if urgent contact your GP or local hospital.
  • It is not uncommon for your child to report feeling “weak” or “funny” in their leg/s following removal of a cast. Avoid high energy activities if this is the case and gradually encourage your child to move. Weakness is usually short-lived (a few hours) but please inform your physiotherapist if you are concerned or the weakness persists for longer than a day.

To assist with making the most of the effect of casting, please encourage:

  • Standing with knees straight.
  • Walking with heels down
  • Doing regular home exercises in casts as instructed by your physiotherapist.

Contact us

Queensland Paediatric Rehabilitation Service
Queensland Children’s Hospital
Level 6, 501 Stanley Street, South Brisbane 4101
t: 07 3068 2950
t: 07 3068 1111 (general enquiries)
f: 07 3068 3909
e: qprs@health.qld.gov.au

In an emergency, always call 000.

If it’s not an emergency but you have any concerns, contact 13 Health (13 43 2584). Qualified staff will give you advice on who to talk to and how quickly you should do it. You can phone 24 hours a day, seven days a week.

Resource No: F185. Developed by the Queensland Paediatric Rehabilitation Service, Children’s Health Queensland. Updated: August 2015. All information contained in this sheet has been supplied by qualified professionals as a guideline for care only. Seek medical advice, as appropriate, for concerns regarding your child’s health.

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