# 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. He is discharged with the cast and returns to the orthopedic clinic 2 weeks later. Which finding requires the nurse to arrange further evaluation of the cast?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630334  
> 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.

He is discharged with the cast and returns to the orthopedic clinic 2 weeks later. Which finding requires the nurse to arrange further evaluation of the cast?

## 보기

1. Toe swelling after long sitting that subsides with elevation
2. Itching under the cast that eases with cool air from a hair dryer
3. Aching in the arms and shoulders after a day on crutches
4. A warm spot on the cast over the heel with a musty odor **✔ 정답**

**정답: 4**

## 해설

A warm area over a bony point and a foul or musty odor suggest a pressure injury or infection under the cast, so the cast may need to be windowed or removed for inspection. Itching, swelling that responds to elevation, and muscle ache from crutch walking are expected.

## 심화 해설

The finding that needs evaluation
Two weeks after casting, a warm spot on the cast over the heel with a musty odor is a warning sign. A warm area over a bony prominence, often called a hot spot, suggests inflammation beneath it, and a foul or musty smell suggests tissue breakdown or infection. Together these point to a pressure injury or infection under the cast, so the cast may need to be windowed or removed for inspection.

Why the heel is at risk
Bony areas such as the heel, malleoli, and the head of the fibula have little soft tissue between bone and cast. If the cast fits tightly, has a rough edge or dent, or if swelling changes, constant pressure can reduce blood flow to the skin and cause a pressure injury. Because the skin is hidden, the first clues are often indirect: localized warmth on the cast surface, drainage staining through the plaster, or odor. Early detection prevents a deep ulcer or infection that could delay fracture healing.

| Finding at 2 weeks | Interpretation | Action |
| --- | --- | --- |
| Toe swelling after long sitting that subsides with elevation | Expected dependent edema | Continue elevation; teach to avoid prolonged dependency |
| Itching relieved by cool air from a hair dryer | Expected | Continue; do not insert objects under the cast |
| Arm and shoulder ache after crutch walking | Expected muscle fatigue | Check crutch fit; weight on the hands, not the axillae |
| Warm spot over the heel with musty odor | Possible pressure injury or infection | Arrange evaluation of the cast |

Why the other findings are expected
Swelling that develops after long sitting and resolves with elevation is dependent edema and responds to the usual measures. Itching under a cast is common as the skin is enclosed, and cool air from a hair dryer is the recommended remedy. Watch out! The client must never push objects such as sticks or pens under the cast to scratch, because they can break the skin or be lost inside and cause the very pressure injury and infection described. Upper-body ache in the first weeks of crutch walking is expected muscle fatigue, as weight is borne on the hands.

Other cast warning signs to teach
Clients should report increasing or new pain, especially a burning pain over one spot, numbness or tingling, toes that become cool, pale, or bluish, swelling that does not improve with elevation, drainage or staining on the cast, odor, fever, and a cast that cracks, softens, or becomes loose or too tight.

Exam takeaway
Key point! A hot spot or a foul or musty odor from a cast suggests pressure injury or infection and requires evaluation. Itching, swelling that resolves with elevation, and crutch-related muscle ache are expected. Teach clients never to insert objects under the cast.

## 임상 시나리오

Cast Complications at Follow-upRecognizing a hot spot and odor
A warm spot over the heel with a musty odor suggests a pressure injury or infection under the cast. Arrange evaluation; the cast may be windowed or removed.

Expected findings: dependent toe swelling that resolves with elevation, itching relieved by cool air, and arm or shoulder ache from crutch walking.

Teach clients to report new localized burning pain, numbness, color change, drainage, odor, fever, or a loose or cracked cast.

CautionNever insert objects under the cast to scratch. They can break the skin or be lost inside and cause pressure injury or infection.

## 핵심 개념

- **Hot spot** — A localized warm area on a cast that may signal pressure injury or infection beneath it.
- **Pressure injury** — Localized damage to skin and tissue from sustained pressure, often over a bony prominence.
- **Windowing a cast** — Cutting an opening in a cast to inspect or treat the skin underneath.
- **Dependent edema** — Swelling in a body part kept below heart level that improves with elevation.
- **Crutch walking** — Ambulation with crutches; body weight is borne on the hands rather than the axillae.

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