/sebin/v/s/HealthLibrary.jpg
bookmark icon Bookmarkprinter iconPrinte-mail icon

Residents Corner

Faculty Corner

Make a Gift

Make a Gift




/sebin/u/t/blankblue.gif

Department of Pediatrics : Academic Divisions : Emergency Medicine : Resident Manual : Orthopedic Emergencies : Splinting

Most non-displaced fractures can be splinted by the ED physician and referred to the Orthopedist for definitive care. For a list of specific injuries and recommendations regarding splinting by us vs. immediate consultation, please refer to the section on Orthopedic Emergencies preceding this section.

All suspected fractures and significant musculoskeletal injuries should be examined by a physician prior to obtaining x-rays in order to verify that the patient is neurovascularly intact (i.e. check for sensation and pulses in the hand after an elbow injury before attempting to rule out a supracondylar fracture radiographically). All injuries with obvious deformities should be temporarily splinted to provide comfort and to prevent further deformation and vascular compromise before the patient goes to the Radiology Suite. Such temporary stabilization of the injury may be achieved with an arm board (just the kind we use to protect IV's) or a pre-fabricated aluminum splint. Keep in mind that not all fractures jump out at you on an initial film, so if there is any doubt about whether or not a fracture is present, just place a splint until a follow-up x-ray can be obtained (particularly important in the child with snuff-box tenderness but no evidence of scaphoid bone fracture on x-ray).

Once a fracture which does not require immediate orthopedic attention has been identified (or you have made the decision to immobilize a suspicious injury), it's time to get down to the business of splinting:

What you need:

  1. Plaster or fiberglass rolls in appropriate widths and soft cotton roll to provide padding (Webril). We are now using a new product called Orthoglass which incorporates the plaster and padding into one product. You may also chose to use fiberglass but overall, for acute injuries, we elect to use plaster but we have fiberglass available for the Orthopedic residents to use if they desire.
  2. Cotton stocking material (stockinette)
  3. Bias wrap or Ace wraps in appropriate width
  4. Bucket and room temperature water
  5. Gloves (otherwise your hands will end up sticky from fiberglass or covered with plaster)

What you do:

  1. USING THE UNINJURED EXTREMITY, measure the length of plaster or orthoglass rolls that will be needed to splint the injured extremity effectively (see the subsequent pages outlining the specific splints for guidelines on what area the splint actually needs to cover).
  2. Place the stockinette on the affected extremity (prevents direct contact of the splinting material with the skin)
  3. Apply webril padding over the stockinette to insure adequate padding along the bony prominences; avoid wrinkles in the webril as they may lead to pressure sores. If using orthoglass, you may skip this step as the webril is included with the plaster.
  4. Position the affected extremity for the best placement of the splint
  5. Wet the plaster or orthoglass with room temperature water and apply (usually requires about 10-15 seconds of immersion); avoid water that is too warm, because the splinting material actually generates heat as it hardens and may result in second degree burns. Excess water may be removed from the splint prior to placement by rolling plaster or fiberglass in a towel
  6. Shape the splint over the large joints
  7. Apply a bias wrap or Ace wrap or a cotton roll over the top of the splint
  8. Shape the splint to its final form and hold in position until the splint hardens (about 15 minutes to achieve complete hardening)
  9. After the splint has been placed and has hardened in the appropriate position, follow-up care must be assured and documented, either with an Orthopedist or with the Primary Care Provider as appropriate.
     
    SPECIFIC SPLINTS AND WHEN TO USE THEM

    (See Table 1 for fracture indications and Diagrams 1-8 for schematics of each splint)

    UPPER EXTREMITY (table 1)
    Fracture typeSplint recommendedComments
    ForearmSugartongUseful for most upper extremity fractures. Must use sling.
    WristVolar (colles')Not for young children.
    ElbowPosterior (long-arm)Must use sling.
    HumerusProximal sugartong or coaptation splint
    ScaphoidThumb spica
    Proximal phalanxThumb spica
    1st metacarpalThumb spica
    Metacarpal and/or proximal phalanxRadial gutter for 2nd/3rd digits
    Ulnar gutter for 4th/5th digits
    PhalanxDigit splint

    SPLINT DIAGRAMS
    Aluminum Splint
    Aluminum
    Buddy Tape Splint
    Buddy Tape
    Dorsal Splint
    Dorsal
    Posterior Elbow Splint
    Posterior Elbow
    Sugar Tong Splint
    Sugar Tong
    Sugar Tong (View 2)
    Sugar Tong
    Thumb Spica Splint
    Thumb Spica
    Thumb Spica Splint (View 2)
    Thumb Spica
    Volar Splint
    Volar
      
  10. Digit (pre-made splints are available)
    1. MP joint at 50 degrees of flexion
    2. IP joint at 15-20 degrees of flexion
  11. Sugar-Tong
    1. Proximal
      • width covers the dorsal and volar aspects of the upper arm
      • length extends from the axilla medially around the elbow to the AC joint laterally
      • 90 degrees of flexion at the elbow and internal rotation at the shoulder
      • must use a sling
    2. Distal
      • width should slightly overlap the radial and ulnar edges of the arm
      • length extends from the dorsal aspect of the knuckles around the elbow to the volar palmar flexion crease (MCP to MCP)
      • 90 degrees of flexion at the elbow and wrist in neutral position
      • placement easiest if patient is facedown on the bed with the injured arm hanging off the edge
      • must use a sling
    3. Proximal plus Distal may be used to immobilize a STABLE elbow fracture
  12. Colles' (volar splint)
    1. width fully covers the volar aspect of the forearm
    2. length extends from proximal fingers to proximal forearm along volar surface of forearm
    3. wrist in neutral position and small degree of flexion of digits at all joints
    4. for use in distal forearm and wrist fractures as an alternative to sugar tong (not to be used in the "wee ones")
  13. Long arm
    1. width covers 1/2 of the arm circumference
    2. length extends from the dorsal aspect of the mid-upper arm, over the olecranon, down the ulnar aspect of the forearm to the distal palmar flexion crease
    3. 90 degrees of flexion at the elbow and forearm in neutral position
    4. placement easiest if patient is facedown on the bed with the injured arm hanging off the edge
  14. Gutter (either radial or ulnar)
    1. width wraps to midline of hand on dorsal and volar surfaces
    2. length extends from the nail base to the proximal forearm
    3. wrist in neutral position
    4. MP joints in 70 degrees of flexion and PIP joints in 20-30 degrees of flexion
    5. to increase comfort, padding may be placed between the fingers
    6. radial gutter splints should have a hole cut for passage of the thumb through the splint
  15. Thumb spica
    1. dimensions are the same as for the gutter splints
    2. wrist in neutral position and thumb abducted and in slight flexion at the MCP and IP
       
      LOWER EXTREMITY

      Fracture typeSplint recommendedComments

      Distal femur
      Proximal tibia/fibula
      Long legCrutches for children over 6 years.
      Distal tibia/fibula
      Ankle
      Foot
      Posterior (short leg)Crutches for children over 6 years.

      Ankle (including soft tissue injuries)
      Stirrup (air splint)Allows for weight bearing. Fits in a shoe.

      SPLINT DIAGRAMS
      Ankle Stirrup Splint
      Ankle Stirrup
      Posterior Leg Stirrup
      Posterior Leg Stirrup
        
  16. Long leg
    1. width covers at least 1/2 of the leg diameter
    2. length extends posteriorly from below the buttock to the heel of the foot (for knee immobilization only, splint may extend from midthigh to three inches above the malleoli)
    3. for fractures, place the knee in flexion and the ankle in neutral position
    4. for knee injuries, place the knee in full extension
    5. best applied with patient prone in parent's lap or on an exam table
    6. crutches for children > 6 years (any younger and they will come back with a broken arm or a concussion!!!)
  17. Posterior (short leg)
    1. width covers at least 1/2 of the leg circumference
    2. length extends posteriorly from the level of the fibular neck over the heel of the foot to the base of the digits
    3. foot in neutral position at 90 degrees to the leg
    4. best applied with child prone in parent's lap or on an exam table
    5. crutches for children > 6 years (see warning above)
  18. Stirrup (sugar tong)
    1. width covers at least 1/2 of the leg circumference
    2. length extends mediolaterally from just below the fibular head, around the heel, to just below the medial aspect of the knee
    3. foot in neutral position at 90 degrees to the leg
    4. fiberglass recommended, as it can endure weight-bearing
    5. crutches for children > 6 years (see above)
    6. use in conjunction with posterior splint in children under 6 years of age

References:
Klig, J.E., Splinting Procedures in Henretig and King, Textbook of Pediatric Emergency Procedures, Baltmore, MD, 1997.

Back | Next