SPLINTING

• Indications:
o Fracture
o Dislocated joint after reduction
o Sprain: torn or stretched ligaments
o Strain: torn or stretched muscles or tendons
o Postoperative immobilization
• Contraindications:
o Absolute: none.
o Relative: Injuries involving open wounds or infections need easily removable splints to allow
soft tissue care.
• Anesthesia: If injury is grossly stable, use IV sedation (see Appendix C).
• Equipment:
o Cast padding (soft roll)
o Plaster/fiberglass
o Lukewarm water
o Ace bandages
o Disposable gloves
• Positioning:
o Ankle/foot: 90° angle between foot and leg, neutral eversion/inversion
o Knee: 15°–20° flexion
o Shoulder: resting at the side of the body
o Elbow: 90° angle between forearm and arm, neutral pronation/supination
o Wrist: neutral supination/pronation, 20°–30° wrist extension
o Thumb: wrist position as above, thumb in 45° abduction, 30° flexion
o Metacarpals, MCP joint, proximal phalanges: wrist position as above, MCP joint in 90° flexion,
DIP and PIP joints in full extension
o IP joints, middle/distal phalanx: full extension at IP joints
• Technique:
o Splint padding
 Apply cast padding to entire area to be splinted with 2–3 inches of proximal and distal
overhang.
 Padding should be applied evenly in a circular fashion from distal to proximal, with each
turn overlapping by 50% of the next turn to allow at least two layers of padding in all
areas (see Figure 9.9).

 Apply extra layers to bony prominences.

 Apply padding while limb is in final splint position to prevent bunching of padding
across joint flexion creases.
o Fiberglass/plaster
  General technique: Immobilize fracture one joint above and one joint below injury.
 Prefabricated fiberglass splints can be measured and cut.
 Plaster splints need 10–12 layers of plaster in upper extremities and 12–15 layers of
plaster in lower extremities.
 Splints are dipped in room-temperature or lukewarm water.
 Excess water is gently squeezed or shaken from the splint.
 Splint is applied to the soft roll and never directly onto the skin. The splint is held in
place by an assistant or the patient.
o Ace wrap
 Wrap Ace bandage around splint with gentle tension.
 Ace wrap should never be tight enough to cause venous compression.
 Hold extremity in desired position until splint hardens (approximately 5–10 minutes with
fiberglass, 10–15 minutes with plaster).
• Specific Splints:
o Posterior elbow splint (see Figure 9.10)
Fig. 9.10.

 Begin 4-inch-wide splint from posterior upper arm, moving across the posterior elbow.
 Extend the splint over the ulnar border of the forearm and hand to just proximal to the
MCP joint.
o Sugar tong forearm splint (see Figure 9.11)
Fig. 9.11.

 Use for forearm /wrist injuries.

 Begin with 3- to 4-inch-wide splint in the palm of the hand at the level of the MCP joints.
 Extend splint up dorsal aspect of the forearm, around the elbow flexed at 90°, down the
volar aspect of the forearm and hand, to just proximal to the MCP joint.
 Be sure that the splint does not limit MCP motion.
o Ulnar gutter splint (see Figure 9.12)

 Used for fourth and fifth metacarpal or phalanx injuries.

 Apply 3- to 4-inch-wide slab from ulnar aspect of proximal forearm down along the ulnar
aspect of the small finger.
 Fold edges around dorsal and volar aspect of hand and ring/small fingers.
 Place the wrist in neutral supination/pronation with 20°–30° extension.
o Radial gutter splint (see Figure 9.13)
Fig. 9.13.

 Used for injuries of the second/third metacarpal or fingers.

 Apply to radial border as above for ulnar side with a hole cut out to allow motion of the
thumb.
 Alternatively, apply two separate 2- to 3-inch-wide slabs to volar and dorsal aspect of
hand and fingers.
o Thumb spica splint (see Figure 9.14)
Fig. 9.14.

 Apply sugar tong splint as above.

 Add an additional 3-inch-wide slab from upper forearm, along radial border, then down
around thumb.
 Thumb IP joint should be included.
o Long leg splint (see Figure 9.15)
Fig. 9.15.

 Used for knee and tibia injuries.

 Apply 4-inch-wide splint beginning at the medial upper thigh and extending down the
medial knee and ankle.
 Continue the splint around the heel and up the lateral side of the ankle and knee to the
lateral upper thigh, forming a U shape.
 For additional stability, apply a 6-inch splint from the posterior upper thigh down to the
posterior aspect of the leg and plantar surface of the foot.
o Ankle splint (see Figure 9.16)

 Use for isolated ankle injuries.

 Apply 4-inch-wide splint beginning at the proximal border of the upper calf, extending
down the medial calf and ankle, and around the heel and up the lateral ankle and lateral
calf.
 For additional stability, apply a 6-inch splint from the posterior upper calf down the
posterior aspect of the lower leg and the plantar surface of the foot.
• Complications and Management:
o Burns
 Splints harden by exothermic reaction and can burn underlying skin.
 Be sure skin is properly padded.
 Never use hot water to moisten splints.
 Avoid overly thick splints.
 If patient complains of significant heat or pain, remove splint and check the underlying
skin.
 If burn occurs, treat with local burn techniques including debridement and topical
Silvadene as necessary.
o Cast sores
  Compression of skin over extended periods can lead to necrosis and breakdown.
 Be sure all bony and tendinous prominences are well padded.
 Be cautious about applying splints in unconscious patients or patients with insensate skin.
 If patient complains of burning pain or discomfort, remove splint and inspect skin.
 If splint is foul-smelling or drainage appears, remove splint immediately and inspect.
 If wound develops, treat with local wound care.
 Avoid indenting the splint with finger pressure while it is hardening.
o Joint contracture
 Long-term immobilization can lead to shortening of ligaments and tendons if improperly
positioned.
 Check and re-check position of splint as it hardens.
 Avoid immobilization for longer than 3 weeks for shoulder and elbow injuries; 6 to 8
weeks for any other injury.
 If contracture develops, begin physical therapy immediately.
 Orthopedics consult.