Case Based Pediatrics For Medical Students and Residents
Department of Pediatrics, University of Hawaii John A. Burns School of Medicine
Chapter XIX.2. Splinting
Erick M. Itoman
March 2002

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This is a 7 year old female who presents to the clinic with a chief complaint of left wrist pain. She was rollerblading with several friends, and was accidentally pushed from behind. She fell forward with outstretched, pronated arms. She denies hitting her head, loss of consciousness, vomiting, and abdominal pain.

Exam: VS T37.0, P105, R20, BP 117/75. She is comfortable, alert and appears to be in no distress. Mild abrasions are noted on her left knee and palmar surfaces of both hands. No obvious puncture wounds are present. She has mild discomfort upon palpation of her left knee, but she is able walk, stand, and jump without difficulty or discomfort. Her right wrist is normal, but tenderness is elicited upon palpation of her left distal radius. Slight wrist swelling is noted, but no angular deformity is present. The remainder of her exam is unremarkable.

Radiographs reveal a non-displaced distal radius fracture of the left wrist without angulation. She is placed in a forearm sugar tong splint, and her mother is given instructions to follow-up with an orthopedic surgeon.


Splints are used to temporarily immobilize fractures, subluxations, sprains or soft tissue injuries. Other indications for splinting include acute arthritis, severe contusions and abrasions, skin lacerations or burns across joints, tendon lacerations, tenosynovitis, animal bites, deep space infections, joint infections, and puncture wounds (1). The goal of splinting is immobilization to minimize pain and prevent further damage to nerves, vessels, muscle, skin, etc. (2). Immobilizing tender joints, as seen in tenosynovitis, hemarthrosis, or acute arthritis, reduces pain and inflammation. Abrasions and lacerations that cross joints can be stretched open if the extremity is not immobilized. Regardless of the initial event, tissue damage results in inflammation. Immobilization of the injured limb minimizes irritation and reduces edema (1). Immobilization of fractures reduces the risk of further displacement, minimizes hemorrhage, soft tissue damage, and risk of neurovascular injury.

All injuries that present with immobility, pain with movement, swelling, reproducible pain on palpation, anatomic deformity, discoloration, or crepitus should be evaluated with appropriate radiographic studies (3). Severe musculoskeletal injuries need immediate orthopedic consultation. These injuries include open fractures, fractures with neurovascular compromise, fractures that are too deformed, angulated, or displaced to adequately splint, and any dislocation that cannot be reduced in the ED. Pediatric patients with sprains warrant special attention. A Salter-Harris type 1 injury may not exhibit any radiographic evidence of a fracture, and may present like a sprain. All children who present with tenderness over the physis (growth plate) of a long bone should be presumed to have a Salter-Harris type 1 fracture injury and immobilized in an appropriate splint (3). The presence of a non-displaced Salter-Harris type 1 fracture is identified clinically during the follow up examination. Persistent tenderness several days after the injury implies the presence of a fracture (to be confirmed by additional radiographs which may show new born formation 7 to 10 days after the injury). Rapid resolution of tenderness implies the absence of a fracture.

The two categories of splints are classified based on their raw materials, plaster and fiberglass. Cardboard, aluminum and other semi-rigid or malleable materials can also be used for temporary splints. Plaster splints are made from gauze material impregnated with plaster of Paris, which is made from gypsum. Gypsum, when heated, loses water and is reduced to a powder. When water is added, the gypsum-powder hardens as the calcium sulfate dihydrate molecules recrystallize (1). The reaction is exothermic and can possibly burn the patient, but most of the time, it just feels warm. Depending on the temperature of the water (hot water allows for a quicker set time) the plaster may take anywhere from 2-8 minutes to set. Although hard, the plaster takes about a day to reach its maximum strength. Plaster has the distinct advantage of molding to the individual's anatomy, but it can be messy and difficult to work with (1). An upper extremity injury may require anywhere from 8-10 layers of plaster while the lower extremity may take 10-20 layers (4). Despite the large amount of material used, plaster is still relatively inexpensive (1). Once the plaster is set, water must be avoided. Excessive water will cause the crystallization to become unstable, making the splint soggy. The newer fiberglass splint materials comes prepackaged with padding. The prepackaging reduces the steps needed to prepare the limb prior to splinting, but increases the cost. The padding also absorbs water and sweat well, minimizing the accumulation of moisture (1). Fiberglass has several other advantages over plaster. It is lighter, stronger, has a quicker set time, and is not as messy as plaster. The fiberglass hardens in minutes and cures in approximately 10-20 minutes (1,4). Fiberglass, because of its prepackaged nature, does not mold to the individual's anatomy as well, so kinking may occur where the splint is bent to fit the limb (4). Kinks, although small, may be a potential sight of irritation causing skin breakdown and pressure injury.

The procedure for splinting should always start with a general inspection of the limb. Abrasions, cuts, and lesions need to be cleaned and dressed. Next, the limb should be rechecked for signs of compartment syndrome and neurovascular compromise. The splint width should be approximately half as wide as the circumference of the extremity. The following steps in the procedure will vary based on the type of split used.

For plaster splints, the plaster strips should be measured and cut to length. Since the splint is used to support the limb, the posterior surface is usually used as a measuring guide. Strips should be cut to a length slightly longer than needed. This will allow the splint to be folded upon itself to provided a smooth edge. A longer length will also allow for contraction of the plaster as it crystallizes (4). Optionally, stockinette (tube sock) can be rolled over the limb and cut to a length slightly longer than needed. The stockinette should look as if a long sock with an open hole has been placed over the extremity. Take time to smooth out the stockinette to prevent pressure spots and kinks at flexion creases. Also, make sure the stockinette is positioned so that there is extra material both proximal and distal to the area to being splinted. Cast padding (e.g., Webril cotton padding rolls) should be rolled over the extremity in a distal to proximal direction. If stockinette has been used, then the cast padding is rolled over the stockinette. Each successive roll of cast padding around the extremity should cover the previous roll by approximately 50-60% (4). This will ensure a double layer of padding over the area to be splinted. Make sure that the "extra" stockinette distal and proximal to the area being splinted is not covered with cast padding. Extra padding should be placed over the bony prominences and the fracture site. This will minimize pressure and discomfort. The plaster should now be immersed in water. The warmer the water, the quicker the plaster will set. With children, the water should be on the cooler side. The plaster will heat up as it hardens, and this may scare and burn a child but this is unlikely. Place the wet plaster on an open towel. Remove excess water, smooth the plaster, then apply the strip to the extremity. Adjust and position the plaster accordingly while smoothing to the contour to the patient's anatomy. While the plaster still soft, fold the proximal and distal ends of the plaster back over itself to provide a smooth edge. If a stockinette is used, fold it over itself, the cast padding, and the plaster. A smooth padded edge should be present at both ends of the splint. An optional cast padding layer can be applied over the splint to prevent the soggy plaster from incorporating into the elastic wrap applied in the next step. Roll an elastic bandage over the outside of the extremity, usually in a distal to proximal fashion, securing the plaster to the extremity. Keep the limb in the desired position until the plaster thoroughly hardens.

Water soluble fiberglass splints involve fewer steps. Fiberglass splint materials come encased in cast padding material rather than as bare sheets of fiberglass. Once the limb has been inspected, and the proper splint width and length are selected, cut the length needed and place the fiberglass splint in water. The warmer the water, the quicker the fiberglass will harden. Remove the fiberglass splint from the water, and place it on a dry towel. Removed the excess water from the fiberglass splint by rolling it in a dry towel and applying pressure to remove water from the fiberglass. This can be repeated until the outside of the fiberglass splint material feels dry. Because the fiberglass is prepackaged, it has enough padding to be directly applied, but stockinette and additional cast padding can be optionally applied over the whole extremity, or just over the bony prominences (4). Once the fiberglass is placed over the extremity it should be molded to the desired shape. The padding material should be stretched over the end of the fiberglass to prevent the sharp fiberglass ends from poking the patient. An elastic bandage should then be applied to secure the fiberglass splint in place (4).

The final step in any splitting procedure should be to check the extremity for signs of neurovascular compromise. Capillary refill should be brisk, and sensation to light touch and pin prick should be intact. The patient should also be able to move the distal anatomy with minimal discomfort.

The patient and or parents need to be advised of the complications of splinting. In fracture cases, where swelling is prominent, the limb may expand in girth. Because the splint is not a rigid cylinder, the elastic wrap permits some expansion due to extremity swelling preventing harmful circumferential pressure by the splint. Nevertheless, neurovascular injury may occur and produce signs such as tingling, numbness, increasing pain, and/or paresis which may indicate the development of a compartment syndrome. If any of these signs or symptoms develop, the patient should be counseled to return to the emergency department immediately. Preventative measures should be taken such as limb elevation and periodic monitoring of the distal anatomy (1). Finally, the patient should be instructed to keep the splint clean and dry. Moisture will soften the skin and the splint, promoting itching, infection, pressure sores, and cast breakdown. Any discomfort on the skin could suggest pressure sores. The patient should be given instructions for follow-up with a contact number in case of complications.

Some common extremity splints include the following examples. Cast padding is applied to the extremity (stockinette optional), the splint material is applied as noted below, and an elastic bandage is rolled on over the extremity such that the splint material properly molds to the shape of the extremity without pressure spots.

Long Arm Posterior Splint (3). Indicated for elbow and forearm injuries, and/or immobilization. The elbow should be flexed at approximately 90 degrees to a position of comfort, and the forearm should be medially rotated 90 degrees (such that the volar side of the forearm is toward the body) with slight dorsiflexion at the wrist. If splinting a supracondylar fracture, position the forearm in a slightly pronated position. The splint should extend from the metacarpophalangeal joint to the upper arm, just distal to the axilla. The splint will be applied on the ulnar surface of the wrist and forearm and extend to the posterior surface of the upper arm.

Posterior Ankle Splint (3). Indicated for ankle sprains and non-displaced fractures of the ankle, foot, and distal fibula. The ankle should be in the proper anatomic position, flexed at approximately 90 degrees. The splint will extend distally from the foot (plantar side of the metatarsal phalangeal joints) to the proximal lower leg (level of the fibular head near the knee), and provides support to the posterior leg and foot. The splint should not impinge on the popliteal fossa when the leg is flexed. The patient should be given crutches (if the child is old enough to use crutches), otherwise encourage light weight bearing or non-weight bearing on the splint.

Ankle Stirrup Splint (also called ankle sugar tong splint) (3). Indicated for injures to the ankle, and ankle immobilization. Unlike the posterior ankle splint, the ankle stirrup splint provides lateral and medial support. The ankle stirrup splint provides superior immobilization for a fracture near the ankle compared to the posterior ankle splint. The splint is folded into a U-shape stirrup. The splint will wrap from the lateral surface of the calf (just distal to the knee), around the plantar aponeurosis and heel, to the medial surface of the calf just distal to the knee. Ideally, wide splint material should be used so that the bottom of the "U" will support the heel to the metatarsal phalangeal joints on the plantar side of the foot. The ankle should be flexed at 90 degrees (the same as for the posterior ankle splint).

Volar Forearm/Wrist Splint (1). Indicated for minor fractures near the wrist, soft tissue injuries to the hand and wrist, and fractures of the carpals and metacarpals. Extend the splint from the metacarpal heads of the palm to the volar surface of the forearm proximal to the elbow. The forearm is placed in the neutral position and the wrist should be slightly dorsiflexed. The palmar end of the splint should be rolled so that the hand can rest in a flexed position over the roll.

Ulnar Gutter Splint. Indicated for fractures of the 4th and 5th metacarpals. The splint material is folded on its long axis such that the ulnar side of the forearm fits into the long gutter formed by the splint. This should extend from the distal 5th finger or metacarpal to the proximal forearm (just distal to the elbow).

Forearm Sugar Tong Splint (3). Indicated for distal radius, wrist, and forearm fractures. Prevents supination and pronation of the wrist, flexion/extension of the forearm, and blunt trauma to the fracture site. This type of splint provides superior immobilization compared to the volar forearm and ulnar gutter splints. Extend the splint from the palmar aspect of the MCP joints, around the elbow, and to the dorsal aspect of the MCP joints. The thumb should be unopposed, and the remaining digits should be allowed 90 degrees of flexion. Flex the elbow approximately 90 degrees to allow a position of comfort. The volar surface of the forearm should be facing the body. The palmar end of the splint should also be folded over (i.e., rolled) to allow the fingers to rest in a flexed position over the roll.

Thumb Spica Splint (3). Indications include a nonrotated, nonangulated, nonarticular fracture of the thumb metacarpal or proximal phalanx. This type of splint can also be utilized for ulnar collateral ligament injuries, and scaphoid tenderness (fracture or suspected fracture). A thumb spica splint is often placed together with a volar wrist splint for suspected scaphoid fractures. The radial aspect of the forearm is placed in the splint so that the splint can form a long U-shape down the length of the splint (similar to the ulnar gutter, but on the radial side). The U-shaped splint will extend from the thumbnail to the mid-forearm. The thumb will be encircled by the distal part of the splint (with the tip of the thumb exposed) to completely immobilize the thumb, and as the splint extends proximally it will open wider to receive the radial surface of the forearm and wrist. The thumb should be slightly abducted and the wrist should be slightly dorsiflexed.


Questions

1. What are the common indications for splinting?

2. What is the purpose of splinting?

3. What are the complications involved with splinting, and how should these complications be evaluated by the patient?

4. Should sprains be splinted in a pediatric patient?

5. Briefly compare and contrast plaster and fiberglass splints.

6. What conditions warrant an orthopedic consult prior to splinting?

7. When choosing a splint strip size, what is the general rule of thumb?

8. What temperature of water should an inexperienced person use when splinting?

9. What is the first step in splinting?

10. What are some reasons for preferring splinting over casting?


Related x-rays/images

Ankle splint: Inaba AS. Ankle Injuries: A Sprained Ankle ? In: Yamamoto LG, Inaba AS, DiMauro R. Radiology Cases In Pediatric Emergency Medicine, 1995, volume 3, case 3. Available online at: www.hawaii.edu/medicine/pediatrics/pemxray/v3c03.html

Thumb spica splint: Inaba AS, Boychuk RB. A Hand Contusion. In: Yamamoto LG, Inaba AS, DiMauro R. Radiology Cases In Pediatric Emergency Medicine, 1994, volume 1, case 14. Available online at: www.hawaii.edu/medicine/pediatrics/pemxray/v1c14.html


References

1. Chudnofsky CR. Chapter 53 - Splinting Techniques. In: Roberts J, Hedges J (eds). Clinical Procedures in Emergency Medicine third edition. 1998, Philadelphia: W.B. Saunders Company, pp. 852-873.

2. Geiderman JM, et al. Chapter 40 - Orthopedic Injuries. In: Rosen P, Barkin R (eds). Emergency Medicine: Concepts and Clinical Practice, fourth edition. 1998, St. Louis: Mosby-Year Book, Inc., pp. 602-624.

3. Klig JE. Chapter 104 - Splinting Procedures. In: Henretig F, Christopher, K (eds). Textbook of Pediatric Emergency Procedures. 1997, Baltimore: Williams & Wilkins, pp. 1025-1038.

4. Carlson DW, et al. Chapter 12.14 - Splinting of Musculoskeletal Injuries. In: Fleisher G, Ludwig S (eds). Textbook of Pediatric Emergency Medicine, fourth edition. 2000, Philadelphia: Lippincott Williams & Wilkins pp. 1886-1458.


Answers to questions

1. Splints are generally used to temporarily immobilize fractures, subluxations, or soft tissue injuries such as ankle sprains.

2. Splints immobilize the extremity, reducing damage to the nerves, vasculature, muscle, and skin. This will minimize edema and pain. Splints also stabilize fractures and prevent further displacement of subluxations.

3. If the splint is too tight it will compress the swollen extremity causing decreased sensation, paresthesia, and pain. The patient should be educated to check for brisk capillary refill, mobility of distal anatomy, numbness, tingling, burning, and increased pain. The immobility of the joint may cause contractures. Mobility of the distal anatomy should be evaluated. Stiffness of the immobilized joint should be expected. Wrinkles in the splinting material may cause pressure sores and skin breakdown, especially over bony prominences. Skin breakdown often starts with burning or itching, and may progress to ulceration.

4. Conservative treatment involves splinting of the extremity. The general rule is, when in doubt, splint. Splinting is indicated with sprains overlaying an open physis, because of the similar presentation to a Salter-Harris type 1 fracture. However, many sprain injuries (ankle sprain is the best studied example), will improve faster with gentle activity compared to total rest or immobilization.

5. Plaster is inexpensive and it allows for anatomic molding. However, it is relatively heavy and it can take longer to set and cure. Fiberglass is a more expensive, prepackaged, strong and light splint that cures quickly, but does not allow exact anatomic molding. For example, for an ankle fracture, plaster splinting results in a heavy splint, compared to a fiberglass splint which is stronger and lighter.

6. Complicated fractures include open fractures, fractures with any neurovascular compromise, fractures that are too deformed/angulated/displaced to adequately splint, and any dislocation which cannot be reduced in the ED.

7. The strip should be approximately 50% of the circumference of the extremity.

8. Cold water slows the curing process in both plaster and fiberglass, but ROOM TEMPERATURE water rather than cold water should be used. Warm water is best avoided since it will add further heat to the exothermic reaction.

9. Inspection. Wounds must be cleaned and dressed. Neurovascular compromise should be ruled out, and documented.

10. Casting forms a rigid cylinder over the extremity. In the first 24 hours following a fracture, swelling within the cylinder may result in vascular compromise (i.e., compartment syndrome). Splinting initially, then casting later is associated with fewer complications compared to early casting. Additionally, if the extremity is already swollen and a cast is applied, the fit of the cast will be loose once the swelling resolves. Casts are generally applied by orthopedic surgeons who are not always available for minor fractures. Splints provide an immediate means of immobilizing the extremity and do not require the immediate presence of an orthopedic surgeon.


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