Chapter 14 – Basic Principles of Splinting in the Emergency Department

Chapter 14 Basic Principles of Splinting in the Emergency Department

Anna L. Waterbrook

Illustrations by Yvonne Chow

Introduction

Splints are generally used as a temporary method of immobilization.
Indications for splinting include fractures, dislocations, sprains, tendon and ligament partial or complete disruptions, joint infections, tenosynovitis, and lacerations.
Equipment needed includes:
- Padding
- Plaster or fiberglass
- Bucket + water
- ACE wrap
- Scissors or trauma sheers
- Gloves

Splint Application

Tips for application of the splint include:
- Make sure to always use two to three layers of padding prior to placement of the splint.
  - Be sure to add extra layers of padding over bony prominences such as elbows and ankles, between digits and at each end of the splint border.
  - Avoid wrinkles.
  - Do not tighten as it can cause ischemia.
- May use plaster or fiberglass material to make a splint.
  - Plaster should be used anytime that it is essential to help maintain stability of the bone or joint, that is, after any reduction is performed or for any potentially unstable fracture.
    - Generally, eight to ten layers of plaster are needed for upper extremity splints, and twelve to fifteen layers of plaster are needed for lower extremity splints.
      - As plaster dries it creates an exothermic reaction.
      - The more layers used increases the risk of burns.
    - Plaster may take up to twenty-four hours to fully cure.
  - Fiberglass is easier to use and more breathable, but is less moldable and therefore does not offer as much stability as a plaster splint.
    - Cures in approximately 20 minutes.
    - Increased risk of burns due to faster setting time.
    - Lighter weight
    - More radiolucent.
    - Fiberglass often comes readymade with one layer of padding, however it is still essential to use extra padding prior to placement of the splint.
  - If possible, include joints above and below the fracture or dislocation in the splint.
  - In general, splint in the position of function.
  - Always assess and document neurovascular status before and after application of a splint.

Complications

Complications include:
- Burns
  - Increased risk with increasing layers of plaster.
- Ischemia
  - Less likely than with a cast.
  - When in doubt, take off the splint if there is ANY concern for ischemia.
  - Advise the patient to ice and elevate the extremity to decrease swelling and risk of ischemia.
- Pressure sores
  - Avoid wrinkles.
  - Make sure there is plenty of padding, especially over bony prominences.
- Infection
  - Ensure there is no open fracture prior to placement of any splint.
  - Clean and dress all wounds prior to placement of the splint.
  - If a high-risk wound is present, consider cutting out a window in splinting material to perform dressing changes and monitor wound.
  - Prophylactic antibiotics are controversial.

Table 14.1. Common Immobilization Techniques and Associated Common Clinical Indications

Common Immobilization Techniques	Common Clinical Indications
Upper Extremity
Sling	Shoulder dislocation Clavicle fracture Acromioclavicular separation Shoulder sprains, strains and other causes of shoulder discomfort, or for mechanical support if splinting the upper extremity
Sling and Swath	Rarely used but may be used for same indications as a sling if extra immobilization is needed
Cuff and Collar	Proximal humerus fracture
Burkhalter (Figure 14.1)	Metacarpal fracture and proximal phalanx fracture
Radial Gutter (Figure 14.2)	Second and third metacarpals, proximal and middle phalanx fracture
Ulnar Gutter (Figure 14.3)	Fourth and fifth metacarpals, proximal and middle phalanx fracture, hamate or pisiform fracture
Volar Wrist (Figure 14.4)	Soft-tissue injuries, sprains/strains and stable fractures of the wrist Carpal tunnel syndrome
Thumb Spica (Figure 14.5)	Scaphoid fracture Thumb metacarpal or proximal phalanx fracture or dislocation
Posterior Long Arm (Figure 14.6)	Stable elbow and forearm injuries
Proximal Sugar-Tong	Humeral fractures
Forearm Sugar-Tong (Figure 14.7)	Wrist and distal forearm fractures
Double Sugar-tong (Figure 14.8)	Elbow and forearm fractures
Lower Extremity
Knee Immobilizer	Patella fracture Patella dislocation or subluxation Knee dislocation after reduction Unstable ligament injury Tibial plateau fracture
Posterior Long Leg (Figure 14.9)	Used in place of knee immobilizer if unavailable or if extremity is too large to fit in an immobilizer Temporary immobilization of femur, knee, or tibia and fibula shaft fractures requiring immediate orthopedic evaluation or surgery
Posterior Short Leg (Figures 14.10A and B)	Distal leg, ankle, tarsal, and metatarsal fractures Reduced dislocations Severe sprains
Ankle Stirrup (Figure 14.11)	Used in combination with the posterior short leg splint (Figures 14.12A and B) for added stability to prevent inversion and eversion of the ankle Ankle sprains, fractures and dislocations
Short-Leg Walking Boot	May be used in place of short-leg splint anytime weight-bearing is allowed. Stable ankle or foot fractures Severe sprains Achilles tendon rupture with a heel lift
Hard-Sole Shoe	Sprains, strains, or contusions Stable toe fractures Stable metatarsal fractures