Noncircular cast immobilization can be accomplished with a Jones bandage or a posterior mold. A Jones bandage has more padding and probably is more comfortable for patients with severe bruising and swelling, but may not accomplish the same degree of immobilization as a posterior mold. The patient should be supine on a stretcher. Apply two to three layers of abdominal pads, extending from the distal foot to just below the knee, and hold them in place with 4-inch elastic bandages. A four-inch cotton cast padding can be applied, in place of the abdominal pads, in a circular fashion overlapping by at least 50 percent with a minimum of three complete layers. The Jones bandage should not be used for more than a couple of days.

A posterior mold is most easily applied if the patient is prone on a stretcher with the knee flexed to 90°. Most emergency departments have a prepackaged padded splint material available. For extra padding, apply a single layer of 4-inch cotton cast padding from the toes to the knee, followed by a 4-inch plaster or fiberglass splint. The wet splint should extend along the plantar surface of the foot and the calf from just distal of the first metatarsal-phalangeal joint to the fibular head ( Fig

268-5). Hold the splint in place with 4-inch elastic bandages. As the splint hardens, keep the ankle at a 90° angle and mold the splint about the instep and malleoli. Use three or four layers of cotton cast padding, if prepackaged splints are not available, followed by 15 to 20 layers of 4-inch plaster fashioned into a slab of appropriate length. If more support is required, especially in the setting of an unstable joint, another slab can be added to give additional medial-lateral support. Size the patient, if necessary, for crutches and instruct in their appropriate use. For a weight-bearing patient, a cast shoe can be applied.

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