ed 103: splinting basics thao m nguyen, md daniel a hirsh, md pediatric emergency medicine emory...

ED 103: splinting basics

Thao M Nguyen, MDDaniel A Hirsh, MD

Pediatric Emergency MedicineEmory University

Children’s Healthcare of Atlanta

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Objectives

Indications & Contraindications Basic Principles Common Mistakes Prepare patient/parent Step-by-step instructions Complications Discharge Instructions

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Indications

Temporary immobilization Protection Pain control

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Contraindications

Compartment syndrome Need for open reduction Skin at high risk for infection

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Basic Principles

Temporary Non-circumferential Non-weight bearing Protect the skin

• Pad bony prominences• Place a dry splint

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Common Mistakes

Placement of a Circumferential splint Placement a Wet splint Placement of a Tight Splint Not allowing time for the fiberglass to adequately

harden

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Patient/Parent Expectations

Placement should not hurt Most injuries feel significantly better with splinting

alone Splint material will get warm when it hardens Should be snug, not tight

• Fingers & toes shouldn’t tingle or turn deep purple

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Step 1: Choose your splints

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Choosing the splint types:upper extremities

Volar• Distal radius/

ulna & wrist fx Sugar Tong

• Distal radius/ ulna & wrist fx

Long Arm• Elbow &

forearm injuries

- Fleisher, 2006 -

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Choosing the splint types:upper extremities

Ulnar Gutter• Boxer’s fx and

uncomplicated 4th & 5th phalangeal fx

Radial Gutter• 2nd & 3rd MCP or

phalangeal fx

- Fleisher, 2006 -

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Choosing the splint types:upper extremities

Thumb Spica• Nonrotated,

nonangulated, nonarticular fx of the thumb MCP or phalanx; gamekeeper’s thumb; scaphoid (navicular fx)

Buddy Tape

- Fleisher, 2006 -

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Choosing the splint type:lower extremities

Posterior leg• Foot, ankle & distal fibula fx• Ankle sprains

Stirrup• Foot, ankle & distal

tibia/fibula fx Cadillac Splint

- Fleisher, 2006 -

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Step 2: Gather all of your supplies

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Splinting Splinting MaterialMaterial

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StockinetteStockinette

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““Cotton Wadding” Cotton Wadding” “Cast Padding”“Cast Padding”

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Ace wrapAce wrap

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ShearsShears

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Step 3: Protect the skin

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Apply stockinette to extremity

Extend it past the proximal and distal ends of where

the splint will end

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Cut out any areas that bunch up that could

damage the skin

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Create thumb hole

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Protect bony prominences

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Cut splint material to proper

size

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Protect the skin by creating ~1.5 cm border of cotton by cutting the

fiberglass

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Step 4: Activate the Fiberglass

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Approximate initial hardening times• Ambient Humidity: 15 min• Cold Water: 5 min• Hot Water: 2 min

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Hot water will cause the fiberglass to harden very

quickly

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Cold water

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Keep padding as dry as possible

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Protect the skin. If cotton padding is wet, dry it.

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Some fiberglass material comes with a thick padded side and a

thin side. Protect the skin. Always place the thick-side to

the skin-side.

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Step 5: Apply the Splint

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Wrap the splint in place—not too loose or too tight. Protect the skin. Do not

apply pressure with finger tips, use a curved palm.

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Allow time for the fiberglass to cure

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Step 6: Check splint placement

Make sure patient has normal sensation distal to splint

Make sure there is normal capillary refill after splint placement

Make sure the splint does not cause any pain

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Splint Complications

PreventionComplications

Check splint after placementIf either of these, replace the splint

Pain or Ineffective Immobilization

Keep splint dryUse minimal water necessary and dry thoroughly before placement

Use paddingAvoid ‘kinks’

Skin breakdown

Keep splint snugCheck distal neurovascular status after placement

Risk of ischemiaCompartment SyndromePossible neurovascular compromise

PreventionComplications

Check splint after placementIf either of these, replace the splint

Pain or Ineffective Immobilization

Keep splint dryUse minimal water necessary and dry thoroughly before placement

Use paddingAvoid ‘kinks’

Skin breakdown

Keep splint snugCheck distal neurovascular status after placement

Risk of ischemiaCompartment SyndromePossible neurovascular compromise

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Discharge Instructions

Protect the skin. Keep splint dry If extremities become tingly or blue, re-wrap the

bandage Don’t allow weight bearing on the splint If splint hurts, or there is increasing pain, TAKE

THE SPLINT OFF! Seek medical attention

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Case 1

12 yo female s/p bike accident, fell and landed on wrists

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Case 2

3 yo male fell while running and landed on leg

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Case 2

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Case 3

16 yo female with left wrist injury ~ 6 wks ago. Extremity was splinted w/o reduction; unable to F/U with orthopedics

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Suggested Reading

Fleisher, GR. Textbook of Pediatric Emergency Medicine, 5th ed, 2006