Under Pressure: The Utility of Spacers in Univalved Fiberglass Casts.

Background: Univalving fiberglass casts after fracture manipulation or extremity surgery reduces the risk of developing compartment syndrome (CS). Previous experiments have demonstrated that univalving decreases intracompartmental pressures (ICPs), but increases the risk for loss of fracture reduction due to altering the mechanical properties of the cast. The purpose of this study was to correlate cast valve width within a univalved cast model to decreasing ICP.

Methods: Saline bags (1 L) were covered with stockinette, Webril, and fiberglass tape then connected to an arterial pressure line monitor. Resting pressure was recorded. A water column was added to simulate 2 groups (n=5 each) of clinical CS: low pressure CS (LPCS range, 28 to 31 mm Hg) and high pressure CS (HPCS, range, 64 to 68 mm Hg). After the designated pressure was reached, the fiberglass was cut (stockinette and Webril remained intact). Cast spacers were inserted into each univalve and secured with varying widths: position #1 (3 mm wide), #2 (6 mm), #3 (9 mm), and #4 (12 mm). Pressure was recorded after cutting the fiberglass and following each spacer placement.

Results: In LPCS and HPCS groups, after univalve and placement of spacer position #1, pressure dropped by a mean of 52% and 58%, respectively. Spacer #2, decreased the pressure by a mean of 78% and 80%, respectively. Both spacer sizes significantly decreased the underlying pressure in both groups. Spacer #3 and #4 progressively reduced pressure within the cast, but not statistically significantly more than the previous spacer widths.

Conclusions: This experimental model replicates the iatrogenic elevation in interstitial compartment pressure due to rigid cast application, not necessarily a self-sustained true CS. Increasing the univalved cast spread by ≥9 mm of the initial cast diameter will reduce pressure to a pre-CS level; however, a spread of only 6 mm can effectively reduce the pressure to <30 mm Hg depending on the initial elevated ICP. Cutting the Webril and stockinette in our model yielded a pressure decrease of 91% and 94% from the starting experimental pressure in the LPCS and the HPCS groups, respectively.

Clinical Relevance: Although the utility of splitting fiberglass casts has been previously demonstrated, we present evidence highlighting the benefit of spacing the split by at least 6 to 9 mm.