# Situation: A 24-year-old man sustained a closed fracture of the left tibia and fibula in a motorcycle crash. After closed reduction, a long-leg plaster cast was applied in the emergency department 1 hour ago, and he is transferred to the orthopedic ward. He has no other injuries and no known drug allergies. Neurovascular checks of the left foot are recorded: 1 hour after casting: toes pink and warm; capillary refill 2 seconds; pulse palpable; toes move and feel touch; pain 4/10 2 hours after casting: same findings; pain 3/10 after prescribed analgesia Which plan for the leg is appropriate during the rest of the first day?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630332  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 24-year-old man sustained a closed fracture of the left tibia and fibula in a motorcycle crash. After closed reduction, a long-leg plaster cast was applied in the emergency department 1 hour ago, and he is transferred to the orthopedic ward. He has no other injuries and no known drug allergies.

Neurovascular checks of the left foot are recorded:
1 hour after casting: toes pink and warm; capillary refill 2 seconds; pulse palpable; toes move and feel touch; pain 4/10
2 hours after casting: same findings; pain 3/10 after prescribed analgesia
Which plan for the leg is appropriate during the rest of the first day?

## 보기

1. At heart level, with ice packs at the sides of the cast
2. Above heart level, with ice packs at the sides of the cast **✔ 정답**
3. Above heart level, with a warm pack over the cast
4. Below heart level, with ice packs at the sides of the cast

**정답: 2**

## 해설

During the first 24–48 hours after casting, swelling is controlled by elevating the limb above heart level and applying ice, provided neurovascular checks stay normal. Only when compartment syndrome is suspected is the limb kept at heart level; heat and a dependent position both add to swelling inside the unyielding cast.

## 심화 해설

Plan for the first day
During the first 24 to 48 hours after casting, swelling under the rigid cast is the main threat. It is controlled by elevating the limb above heart level and applying ice at the sides of the cast, provided neurovascular checks stay normal. His checks are normal at 1 and 2 hours: toes pink and warm, capillary refill 2 seconds, palpable pulse, intact movement and sensation, and pain easing from 4/10 to 3/10 after analgesia. With normal, stable neurovascular checks, the leg is elevated above the heart with ice packs at the sides of the cast.

Why elevation and ice reduce swelling
A fresh fracture causes bleeding and inflammation, and a plaster cast cannot expand. If swelling builds, pressure inside the cast rises and can compress vessels and nerves. Elevation above the heart uses gravity to promote venous and lymphatic return. Cold causes vasoconstriction and reduces fluid leakage and pain. Ice packs are placed at the sides of the cast in plastic bags so the plaster stays dry and is not dented, and they are applied intermittently.

| Position and therapy | Effect | Assessment |
| --- | --- | --- |
| At heart level, with ice | Used when compartment syndrome is suspected | Not indicated; checks are normal |
| Above heart level, with ice | Reduces early swelling | Correct |
| Above heart level, with warm pack | Heat dilates vessels | Increases early swelling |
| Below heart level, with ice | Dependent position | Edema gathers under the rigid cast |

When the plan changes
Watch out! If compartment syndrome is suspected, the limb is kept at heart level, not elevated, because elevation lowers arterial pressure to the compartment and can reduce perfusion further. Warning signs include pain out of proportion to the injury, pain on passive stretch of the toes, increasing pain despite analgesia, numbness or tingling, and, later, pallor, coolness, and loss of pulse. The nurse reports these at once; the cast may need to be split or removed. In this client, pain is decreasing and all checks are normal, so elevation is appropriate.

Ongoing nursing care
The nurse continues neurovascular checks at the frequency ordered, supports the wet plaster cast on pillows with the palms rather than the fingertips to avoid dents, leaves it uncovered to dry, and teaches the client to report increasing pain, numbness, or color change immediately.

Exam takeaway
Key point! Fresh cast with normal checks: elevate above the heart and apply ice for the first 24 to 48 hours. Suspected compartment syndrome: heart level and urgent report. Never apply heat or keep the limb dependent in the early period.

## 임상 시나리오

Positioning a Fresh Leg CastControlling swelling in the first 24 to 48 hours
With normal neurovascular checks and easing pain, elevate the leg above heart level and apply ice packs at the sides of the cast in plastic bags.

Heat dilates vessels and increases swelling; a dependent leg gathers edema under the rigid cast.

Support the wet plaster with palms, not fingertips, let it dry uncovered, and continue neurovascular checks as ordered.

CautionIf compartment syndrome is suspected, such as pain out of proportion or pain on passive toe stretch, keep the limb at heart level and report at once.

## 핵심 개념

- **Neurovascular check** — Assessment of color, warmth, capillary refill, pulse, movement, sensation, and pain distal to an injury.
- **Compartment syndrome** — Rising pressure within a closed muscle compartment that compromises circulation and nerves.
- **Elevation** — Raising a limb above heart level to promote venous return and reduce swelling.
- **Closed reduction** — Realignment of fractured bone ends without surgical incision.
- **Capillary refill** — Time for color to return to a nail bed after pressure; normally under about 2 to 3 seconds.

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