SPLINTING

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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).

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Apply extra layers to bony prominences. Apply padding while limb is in final splint position to prevent bunching of padding across joint flexion creases. Fiberglass/plaster
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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.
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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. Sugar tong forearm splint (see Figure 9.11) Fig. 9.11.
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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. Ulnar gutter splint (see Figure 9.12)
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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. Radial gutter splint (see Figure 9.13) Fig. 9.13.
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Used for injuries of the second/third metacarpal or fingers.

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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. Thumb spica splint (see Figure 9.14) Fig. 9.14.

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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. Long leg splint (see Figure 9.15) Fig. 9.15.
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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. Ankle splint (see Figure 9.16)
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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
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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. 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.
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