Abstract
BACKGROUND:
Acute fractures often require prolonged immobilization, which is frequently associated with significant pain and physical discomfort. This study aimed to evaluate the efficacy of an innovative birch sawdust–plaster mixture in reducing pain and improving clinical outcomes compared with traditional plaster of Paris.
MATERIALS AND METHODS:
A single-blind, true experimental design was conducted between May and September 2025 in Baghdad, Iraq. A total of 56 adult patients with upper limb fractures who met the inclusion criteria were recruited and randomly allocated into two groups: the intervention group (n = 27, sawdust-plaster back-slab) and the control group (n = 29, traditional back-slab). Randomization was achieved using sequentially numbered, opaque, sealed envelopes. Data were collected using a sociodemographic sheet and the Visual Analogue Scale (VAS). Statistical analysis was performed using SPSS version 30 employing independent t-tests and Chi-square tests to compare outcomes.
RESULTS:
The intervention group demonstrated a statistically significant reduction in pain scores (25.24 \pm 4.1) compared with the control group (31.53 \pm 5.2; P = 0.039). In addition, the intervention group reported a shorter duration to reach clinical comfort (24.37 days) and a higher prevalence of mild pain levels (77.8%) postintervention. While age influenced pain perception in the intervention group, the primary improvements were attributed to the material’s properties.
CONCLUSIONS:
The sawdust–plaster mixture is significantly more effective than traditional casting in reducing pain and accelerating clinical recovery. To improve patient outcomes, we propose that healthcare facilities integrate this low-cost and sustainable mixture into standard orthopedic protocols. Furthermore, it is recommended that nursing professionals and policy-makers advocate for the use of such eco-friendly materials to enhance patient satisfaction and minimize the physical burden of immobilization.
Keywords: Clinical recovery, orthopedic nursing, pain reduction, patient comfort, sawdust-plaster mixture
Introduction
Musculoskeletal disorders represent a major source of global disability and rank among the leading causes of functional impairment worldwide, placing a substantial burden on healthcare systems and surgical services. Road traffic accidents (RTAs) are among the principal contributors to traumatic injuries and mortality, particularly in low- and middle-income countries, where the majority of orthopedic trauma cases occur.[1] Fractures constitute a significant proportion of these injuries and require timely and effective management to ensure proper bone alignment, prevent joint stiffness, reduce complications, and restore functional outcomes.[2] Conventional fracture management commonly involves immobilization through closed reduction followed by the application of plaster casts or splints to stabilize the affected limb and promote healing.[3] Despite their widespread use, traditional plaster of Paris (PoP) casts present several limitations, including excessive weight, poor air circulation, prolonged drying time, and patient discomfort, which may negatively affect mobility, hygiene, and overall satisfaction.[4,5] Furthermore, complications such as skin irritation, pressure sores, and restricted daily activities have been frequently reported.[6] The epidemiology and types of fractures vary across regions according to demographic characteristics, lifestyle patterns, occupational hazards, and socioeconomic status, with certain populations exhibiting increased susceptibility due to environmental factors or osteoporosis.[7,8] To overcome the shortcomings of conventional casting materials, modern alternatives such as fiberglass and three-dimensional (3D)-printed splints have been introduced, offering advantages including lighter weight, improved ventilation, and enhanced comfort.[9,10] However, these technologies are often costly and may not be readily accessible in resource-limited settings, limiting their practical implementation.[11] Therefore, the development of affordable, lightweight, and effective immobilization materials remains a clinical priority. A novel sawdust–plaster composite material may represent a promising low-cost alternative that combines adequate rigidity with reduced weight and improved patient comfort. This study aimed to evaluate the efficacy of this novel composite material in reducing pain and enhancing fracture healing outcomes compared with conventional plaster casts through a randomized clinical trial.[12,13,14,15,16]
There is a critical necessity to develop sustainable, cost-effective, and patient-centered immobilization materials that can reduce the physical distress associated with standard casting. Grounded in Watson’s Theory of Human Caring, this study emphasizes the importance of creating a “healing environment” by reducing physical pain through innovative nursing interventions. Utilizing locally available materials, such as sawdust, offers a potential solution to improve the physical properties of casts making them lighter and more comfortable without compromising structural integrity. The practical purpose of this study was to evaluate the efficacy of a novel sawdust–plaster mixture compared with traditional plaster of Paris in terms of pain reduction and clinical comfort among patients with upper limb fractures. By assessing these outcomes, the study aims to provide a viable, low-cost alternative for orthopedic care that enhances the quality of life and recovery for fracture patients.
Materials and Methods
Study design and setting
A randomized controlled trial (RCT) design was carried out to investigate the Efficacy of a novel sawdust-plaster cast related to pain reduction and improved healing among fracture patients: A randomized clinical trial. The research was conducted at the Baghdad Al-Rusafa Health Department at Al-Kindi Teaching Hospital, and the Baghdad Health Department, Al-Karakh, at Al-Yarmouk Teaching Hospital.
Study participants and sampling
The study’s standards ensure that every eligible participant with a upper extremity fracture adult >18 years old has an equal opportunity to be selected, making the representative sample of 56 patients divided into an intervention group (n = 27) and a control group (n = 29) accurate to the broader population. Inclusion criteria: To qualify, participants must be adults over the age of 18 who are literate, have recently sustained a fracture in the upper limbs, have no psychiatric conditions, and are willing to join the study. Exclusion criteria: Individuals were not included in the study if they declined to participate, had a physical impairment, were on regular tranquilizers or sedatives, had a prior history of mental health issues, had a confirmed fracture, had existing conditions that could influence healing or pain perception (such as severe arthritis or neurological disorders), were unable to adhere to the study protocol or complete necessary evaluations (for instance, due to cognitive impairment), or had already received treatment for the current fractureas illustrated in Figure 1.
Figure 1.
Consort flow diagram of study[17]
Data collection tools and technique
Data were collected using a two-part instrument designed to assess the efficacy of the intervention:
Part I: Sociodemographic and Clinical Sheet: Developed by the researchers to collect baseline data, including age, gender, residence, marital status, body mass index (BMI), and fracture type.
Part II: Outcome Measurement Tools:
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Visual Analogue Scale (VAS): Used to measure pain intensity. It consists of a 10 cm (100 mm) horizontal line, where 0 represents “no pain” and 10 represents “worst possible pain.”
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Clinical Comfort and Healing Duration Scale: A structured scale was used to record the time (in days) required to reach clinical comfort and the ability to perform basic limb movements without distress.
Scoring: Higher scores indicated higher levels of physical comfort and improved tolerance of the immobilization material.
Validity and reliability
Content Validity: The tools were reviewed by a panel of 10 experts in the fields of orthopedic surgery and nursing to ensure the clarity and relevance of the items. All suggestions were incorporated into the final version.
Reliability: A pilot study was conducted on 10% of the sample (not included in the final analysis). The internal consistency of the comfort scale was assessed using Cronbach’s alpha, which yielded a coefficient of 0.84, indicating high reliability. The stability of the VAS was confirmed through a test-retest method with a correlation coefficient of 0.91.
Fifty-six patients with fractures were randomly assigned to one of two groups: the intervention group (n = 27) received the sawdust-plaster cast, and the control group (n = 29) received a normal cast. The study, which ran from May to September 2025, employed a single-blind, true experimental design to ensure unbiased findings. The pain and healing were measured using a Visual Analogue Scale (VAS).”[17,18,19] The confidentiality of participant information will be rigorously upheld.[20,21,22] And the healing time was recorded.
The study tools were used in this study as follow:
Tool I: demographic information: Patient’s Medical History: It was developed by the researcher to collect data related to socio demographic characteristics. It was consisted: adult’s bio-sociodemographic characteristics: including patient’s age, age groups and marital status, educational level, sex, and occupation.
Tool II: Pain intensity scale: Note: Measured before and after casting and casting:
0 = No pain, 1–3 = Mild pain (bothersome, slightly interfering with daily activities), 4–6 = moderate pain (interfering significantly with daily activities), 7–10 = Severe pain (disabling; unable to perform daily activities) The Visual Analogue Scale (VAS) for pain is a widely utilized tool for assessing pain intensity in real-time settings. This instrument consists of a 100 mm linear scale ranging from 0 to 100. On this scale, scores from 0 to 4 represent no pain, 5 to 44 indicate mild pain, 45 to 74 denote moderate pain, and 75 to 100 correspond to unbearable pain. The scale employs a rating mechanism and scoring methodology, utilizing numerical values to express pain intensity, categorized as mild, moderate, or severe. The VAS, as conceptualized by has proven to be a reliable instrument for quantifying acute pain, with a recorded reliability coefficient of 0.97%.[23]
Tool III: A clinical standard healing duration (5–7 days)
3. Randomization: The researchers coded all the 56 participants and used yellow random selection and randomly assigned.is done by Random draw. The first Random draw is by placing two cards in a glass jar, writing on the first to participate and the other to not participate. Then the participant enters the second Random draw. There are also four cards on the table. He placed four cards on the table: the red color is an intervention group with fracture (A), the yellow color is a control group with Fracture (a). After the card is drawn by the patient, it returns to its place to equal opportunities for all the sample when collected, until the required number is reached.
Data were collected as follows:
The study was conducted through the flowing mention procedure. It was carried out by the researcher to collect baseline data and to assess patient who met the criteria. Then, the researcher began to explain the objective of the study to the patient to cooperation. Preparing the, needed equipment casting fundamental techniques in the management of fracture injuries, serving to immobilize affected areas and facilitate healing. These modalities are essential for various conditions, with specific applications and considerations that practitioners must understand to optimize patient outcomes. The following sections outline the key aspects of casting and splinting in musculoskeletal care. Casting and splinting are essential modalities in musculoskeletal care, particularly for immobilizing fracture and other injuries. These techniques aim to stabilize the affected area, promote healing, and prevent further injury. To execute the immobilization techniques, the mixture is placed in layers to be a thermal insulator and maintain the temperature of the affected part and reducing the risk of thermal burns from the exothermic reaction, thus increasing blood flow and healing and reducing pain. Mix 5 grams of sawdust with 5 grams of gypsum and place the mixture in the third, sixth, and ninth layers of gypsum. The experiment went through several stages, including the criteria for selecting sawdust, which must be from a single source and at a single degree of grinding, in order to achieve hardness, solidity, lightness, and cohesion. The mixture was applied in several tests to understand mechanisms of action (effectiveness).
Statistical analysis
The data were using the Statistical Package for the Social Sciences (SPSS) version 30. The statistical methodologies employed for the purpose of data analysis and evaluation of outcomes encompassed the following: Descriptive Statistics to ascertain demographic characteristics The Mann-Whitney Test was utilized to identify statistically significant differences among the groups. The Chi-square test was applied to examine the correlation relationships between socio-demographic variables and both the levels of pain and healing time.
Results
The demographic [Table 1] characteristics of the sample show that the intervention group (n = 27) had a higher percentage of males (85.2%) compared with the control group (75.9%), and a mean age of 26.00 ± 5.015, with the largest proportion aged 18–27 (48.1%), whereas the control group (n = 29) was predominantly aged 28–37 (69.0%); regarding BMI, 48.1% of the intervention group had a healthy weight, while 62.1% of the control group were overweight, with a notable difference in residential distribution as 96.3% of the intervention group lived in urban areas compared with 79.3% of the control group; furthermore, the intervention group was more balanced between single (51.9%) and married (48.1%) statuses, while the control group was predominantly married (75.9%); both groups’ highest educational level was elementary school graduate (55.6% for the intervention group and 62.1% for the control group), and the most common monthly income for both groups was 601,000–900,000 (63.0% and 93.1% respectively).
Table 1.
Distribution of the sample according to their demographic characteristics
| Characteristics | Intervention group (n27) | Control group (n29) | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|
|
|
|
|||||||||
| F | % | F | % | |||||||
| Sex | Male | 23 | 85.2 | 22 | 75.9 | |||||
| Female | 4 | 14.8 | 7 | 24.1 | ||||||
| total | 27 | 100.0 | 29 | 100.0 | ||||||
| Age | 18–27 | 13 | 48.1 | 7 | 24.1 | |||||
| 28–37 | 11 | 40.7 | 20 | 69.0 | ||||||
| 38–47 | 2 | 7.4 | 2 | 6.9 | ||||||
| 48–57 | 1 | 3.7 | – | – | ||||||
| Total | 27 | 100.0 | 29 | 100.0 | ||||||
| Mean±SD | 26.00±5.015 | |||||||||
| BMI | health weight | 13 | 48.1 | 9 | 31.0 | |||||
| overweight | 12 | 44.4 | 18 | 62.1 | ||||||
| obese stage 1 | 2 | 7.4 | – | – | ||||||
| obesity stage 2 | – | – | 2 | 6.9 | ||||||
| Total | 27 | 100.0 | 29 | 100.0 | ||||||
| Residence | Urban | 26 | 96.3 | 23 | 79.3 | |||||
| Rural | 1 | 3.7 | 6 | 20.7 | ||||||
| Total | 27 | 100.0 | 29 | 100.0 | ||||||
| Marital-status | Single | 14 | 51.9 | 7 | 24.1 | |||||
| Married | 13 | 48.1 | 22 | 75.9 | ||||||
| Divorced | – | – | – | – | ||||||
| Total | 27 | 100.0 | 29 | 100.0 | ||||||
| Educational level | Can read and write | 3 | 11.1 | – | – | |||||
| Elementary school graduate | 15 | 55.6 | 18 | 62.1 | ||||||
| Middle school graduate | 7 | 25.9 | 7 | 24.1 | ||||||
| Preparatory school graduate | 1 | 3.7 | – | – | ||||||
| Diploma graduate | 1 | 3.7 | – | – | ||||||
| Bachelor's degree graduate | – | – | 4 | 13.8 | ||||||
| Total | 27 | 100.0 | 29 | 100.0 | ||||||
| Monthly income | 300,000–600,000 | 7 | 25.9 | – | – | |||||
| 601,000–900,000 | 17 | 63.0 | 27 | 93.1 | ||||||
| 901,000 and above | 3 | 11.1 | 2 | 6.9 | ||||||
| Total | 27 | 100.0 | 29 | 100.0 | ||||||
F=Number of frequencies, %=Percentage, M=Mean, SD=Standard Deviation. 18.5–24.9 health weight. 25–29.9 overweight 30–34.9 obese stage 135–39.9 obesity stage 2
Based on the data provided in Table 2, the results indicate that the intervention group experienced a statistically significant reduction in both pain and healing duration compared with the control group. For pain, the intervention group had a lower mean score of 25.24 compared with the control group’s mean of 31.53 (P = 0.039). This statistically significant difference suggests that the intervention was effective in reducing pain. Similarly, for healing duration, the intervention group had a shorter mean duration of 24.37 compared with the control group’s mean of 32.34 (P = 0.035). This statistically significant difference shows that the intervention was also effective in speeding up the healing process.
Table 2.
Differences between pain and healing duration in patients with fracture
| Variable | Groups | n | Mean | Sig. | ||||
|---|---|---|---|---|---|---|---|---|
| Pain | Control | 29 | 31.53 | .0390 | ||||
| Intervention | 27 | 25.24 | ||||||
| Total | 56 | |||||||
| Intervention | 27 | 36.37 | ||||||
| Total | 56 | |||||||
| Healing duration | Control | 29 | 32.34 | 0.035 | ||||
| Intervention | 27 | 24.37 | ||||||
| Total | 56 | |||||||
The data [Table 3] show a marked improvement in pain levels for the Study Group (Intervention) following the intervention. Before the intervention, 70.4% of the Study Group experienced moderate pain, and only 25.9% had mild pain. After the intervention, this trend was reversed, with a significant majority (77.8%) reporting mild pain and only a small percentage (14.8%) remaining in the moderate pain category. By contrast, the Control Group showed a less dramatic shift. While no one had severe pain after the study period, the percentage of patients with moderate pain remained high (48.3%), while 51.7% shifted to mild pain. The study group had a shorter average healing duration, with a mean of 5.74 ± 0.984 days, compared with the Control Group’s mean of 6.31 ± 0.967 days. This difference is also reflected in the frequency distribution. A majority of the Study Group (58.6%) healed in 5 days, while only 34.5% of the Control Group achieved this. The majority of the Control Group (65.5%) required 7 days to heal, a duration experienced by only 34.5% of the Study Group. This indicates the intervention was effective in accelerating the healing process.
Table 3.
Descriptive analysis of pain and healing duration in patients with fracture
| Variable | Study group | Control group | ||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
|
|
|||||||||||||||
| Pre | Post | Pre | Post | |||||||||||||
|
Pain | ||||||||||||||||
| Mild | 7 | 25.9 | 21 | 77.8 | – | – | 15 | 51.7 | ||||||||
| Moderate | 19 | 70.4 | 4 | 14.8 | 15 | 51.7 | 14 | 48.3 | ||||||||
| Severe | 1 | 3.7 | 2 | 7.4 | 14 | 48.3 | – | – | ||||||||
| Total | 27 | 100. | 27 | 100.0 | 29 | 100.0 | 29 | 100.0 | ||||||||
|
Healing duration | ||||||||||||||||
| F | % | Mean±SD | F | % | Mean±SD | |||||||||||
|
| ||||||||||||||||
| 5 day | 17 | 58.6 | 5.74±0.984 | 10 | 34.5 | 6.31±0.967 | ||||||||||
| 7 day | 10 | 34.5 | 19 | 65.5 | ||||||||||||
| Total | 27 | 100.0 | 29 | 100.0 | ||||||||||||
In the intervention group (n = 27) [Table 4], there was a statistically significant relationship between age group and pain (P = 0.018). This suggests that the age of the patients was related to their pain levels. No other socio-demographic variables, including sex, educational level, marital status, BMI, residence, or monthly income, showed a significant association with pain. For the control group (n = 29), a statistically significant relationship was found between BMI and pain (P = 0.034). This indicates that the BMI of the patients was related to their pain levels. None of the other socio-demographic variables showed a significant relationship with pain.
Table 4.
Correlation relationships between socio-demographic variables and pain and healing duration in patients with fracture
| Variables | Chi-square tests |
|||||||
|---|---|---|---|---|---|---|---|---|
| Intervention group (n27) | Control group (n29) | |||||||
|
Pain | ||||||||
| Socio Demographic | Value | Sig | Value | Sig | ||||
| Age Group | 15.318a | 0.018** | 2.311a | 315.0 | ||||
| Sex | 0.236 | 0.472 | 0.109a | 0.742 | ||||
| Educational Level | 4.684a | 0.791 | 1.332a | .5140 | ||||
| Marital Status | 3.015a | 0.221 | 1.981a | .1590 | ||||
| BMI | 3.876a | 0.423 | 6.751a | .0340* | ||||
| Residence | 0.297a | 0.862 | 0.009a | .9240 | ||||
| Monthly Income | 7.187a | 0.126 | 2.005a | .1570 | ||||
aChi-square value, *Significant at P<0.05. **highly significant at P<0.01
Discussion
The present study demonstrates that using a sawdust–plaster mixture significantly improved pain and clinical recovery outcomes compared with traditional plaster casts. A marked shift in pain intensity was observed, with 77.8% of the intervention group reporting mild pain compared with 51.7% in the control group (P = 0.039). This finding aligns with the core tenets of Watson’s Theory of Human Caring, which emphasizes that modifying the “healing environment” through lighter, more comfortable materials can directly reduce physical distress and promote transpersonal wellbeing. Our results regarding pain reduction are consistent with earlier trials that highlight the efficacy of innovative, nonpharmacological and supportive nursing interventions. For instance, the nearly 46% reduction in pain observed in our study mirrors the effectiveness of nonpharmacological techniques in reducing procedural pain in adults[24,26], and supportive care such as foot massage and exercise interventions[25]. Moreover, clinical nursing rehabilitation programs have demonstrated substantial pain improvements postsurgery[27], and cooling therapy has reduced postoperative pain levels[28]. Nonpharmacological sensory interventions such as music medicine also show efficacy in lowering pain scores among patients undergoing painful procedures[29]. These findings align with our study results, emphasizing that patient-centered, low-cost nursing innovations like the sawdust–plaster mixture can significantly enhance pain relief and clinical recovery outcomes. In terms of recovery, the intervention group achieved faster clinical comfort, consistent with recent evidence suggesting that personalized multimodal interventions produce superior functional recovery. The demographic distribution in our study suggests that younger age and healthier BMI in the intervention group may have acted as synergistic factors. Furthermore, our finding that BMI was a significant predictor of pain in the control group (P = 0.034) but not in the intervention group suggests that the sawdust–plaster mixture may mitigate the detrimental impact of body weight on cast pressure. This finding In accordance with many studies.[30,31,32] By providing a lowcost, patientcentered alternative, this study reinforces the necessity of integrating sustainable nursing innovations into orthopedic practice, particularly in resourcelimited settings where expensive alternatives are not viable.
Limitations and recommendation
Despite the fact that our study used a small adult sample, the results were representative and statistically significant. Second, lack of previous research studies on the scope of our research related to “assessing patients with fracture”.
Conclusions
The intervention significantly reduced pain scores and healing duration compared with the control group, with 77.8% experiencing mild pain post intervention. The intervention group was predominantly male, younger, and urban, while the control group was overweight and married. The study demonstrates the intervention’s effectiveness in accelerating patient recovery and improving quality of life, providing valuable insights for developing targeted health programs.
Ethical approval
Ethical approval to conduct the study was taken from scientific research ethical committee at the Faculty of Nursing at (Date/Number: DST114/19/2/2025) was obtained from the health institution where the study would be conducted. In accordance with the Helsinki Declaration, the patients were informed that the study data would only be used in the study, and that their privacy would be ensured. Their written consent was obtained. The study was registered in Clinical Trials registration: The IRCT code for the trial, was IRCT Id IRCT20240814062761N1. We followed all guidelines set forth by the World Medical Association’s Declaration of Helsinki before the first participant was recruited.
Author’s contributions
The manuscript has been read and approved by all the authors, that the requirements for authorship as stated earlier in this document have been met, and that each author believes that the manuscript represents honest work. All authors were involved in initial conception of the paper and in the design. All authors contributed to the preparation of the final manuscript. All authors have agreed on the final version by drafting the article or revising it critically for important intellectual content.
Data availability statement
Data and materials for the study are available upon request from the corresponding authors.
Conflicts of interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Acknowledgment
The authors would like to thank the all participating in this study.
Funding Statement
The author(s) received no financial support for the research, authorship, and/or publication of this article.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data and materials for the study are available upon request from the corresponding authors.