Version May 2024
INTRODUCTION — The basic principles, method of application, and description of specific splints for the upper and lower extremities will be discussed here. Closed reduction and casting for distal forearm fractures in children are discussed separately. (See "Closed reduction and casting of distal forearm fractures in children".)
GENERAL PRINCIPLES — Splinting plays a major role in the management of musculoskeletal injuries, including treatment of overuse and soft tissue injuries (eg, tendonitis and sprains), as well as for traumatic injuries like extremity fractures and joint dislocations. Immobilization of the extremity through splinting may serve to decrease pain and bleeding, and prevent further soft tissue, vascular, or neurologic compromise [1-7]. Splinting may also provide definitive treatment for some injuries [8-10].
Compared with casts, splints permit swelling and may prevent neurovascular compromise. Timely splinting (as soon as possible after the injury) is recommended in most cases. Close attention to detail and familiarization with proper splinting technique can increase patient comfort and decrease the likelihood of further injury.
However, preliminary evidence suggests that many splints are applied incorrectly with the potential for causing unnecessary injury. As an example, in a prospective, observational study that evaluated 275 splints applied for pediatric fractures in emergency departments or urgent care centers, 93 percent were deemed to have been applied incorrectly, with 77 percent of the splints having the application of the elastic bandage directly to the skin, 59 percent noted to have improper positioning, and 52 percent with an inappropriate splint length, most commonly too long and not permitting free range of motion at the metacarpal joint [11]. Skin or soft tissue complications occurred in 40 percent of patients; excessive swelling was most frequent (28 percent).
EQUIPMENT — Splints have traditionally been made of plaster of Paris, but in recent years many different types of splinting materials have become available. These include pre-formed plaster, fiberglass, pre-padded fiberglass, malleable aluminium, air splints, vacuum splints, and pre-formed "off-the-shelf" splints for nearly every body part.
Preformed splints — The choice between pre-formed splints and custom splints is largely one of convenience and compliance.
Commercial pre-formed splints are typically made of Velcro and hard plastic. They are very convenient and come in a variety of sizes to fit most patients. However, since these splints are not custom-molded, they do not provide the same level of immobilization as custom built splints. Additionally, patients can easily remove commercial splints, potentially causing delayed healing, fracture displacement, or re-injury. Hence, custom splinting with plaster, fiberglass, or similar materials may be preferred when precise and continuous immobilization is required.
Manufactured splints — The equipment necessary for the application of a manufactured splint includes [12,13]:
●Cotton bandage (eg, Webril) for padding
●Plaster slabs or rolls or pre-padded fiberglass splint material (eg, OCL and Orthoglass) of various widths (2, 3, 4, and 6 inches [5, 7.5, 10, and 15 cm])
●Room temperature water
●Elastic bandage (eg, Ace bandage)
●Adhesive tape
Most splints are made from plaster or fiberglass. Plaster splints are made from gauze that is impregnated with plaster of Paris, a powdered form of gypsum. When water is added, the gypsum recrystallizes and hardens in a heat-releasing reaction [3]. To minimize the risk of burns, use water that is no warmer than room temperature. Plaster splints take between 2 and 8 minutes to set, but they do not reach their maximum strength for approximately 24 hours. Plaster splints are easier to mold and are less expensive than fiberglass splints. However, they are more difficult to apply and become soggy when wet [3].
Fiberglass and other synthetic splints (eg, Orthoglass, OCL, and Velcro splints) usually are pre-padded and easier to apply. In addition, synthetic splints set more quickly and are lighter and longer-wearing, and are water-resistant [3-5,12]. However, they are more expensive and do not mold as well as plaster splints.
More sophisticated prefabricated splints, consisting of plastic shells lined with air cells, foam, or gel components, are widely available. These splints are often used for soft tissue injuries or bony injuries that require prolonged periods of immobilization [3-5].
Air splints (also called air casts) provide less support than plaster or fiberglass splints (picture 1). They can be used to treat ankle sprains and low-risk fractures of the distal fibular physis (ie, Salter-Harris Type I fractures of the distal fibula). Air splints prevent eversion/inversion movement while permitting free flexion/extension. Furthermore, the amount of air in the splint can be increased as swelling resolves in order to maintain support during healing.
BASIC TECHNIQUES — Advise field personnel to splint injuries suspected to be fractures before the patient is transported for medical evaluation. Commercial splinting devices are available and easy to use. If commercial devices are unavailable field personnel can manufacture splints from other available, malleable, semi-rigid material [4].
The following techniques apply to splinting applied by medical personnel [1-6,12,14]:
●Provide pain control, as needed, prior to splinting. Ibuprofen provides reasonable pain control for many injuries. Patients with significant pain require opioids (eg, intranasal fentanyl or intravenous morphine). (See "Pain in children: Approach to pain assessment and overview of management principles", section on 'Pharmacologic therapy'.)
●Assess the full extent of the injury and obtain adequate exposure for splint application. Obtain emergent orthopedic surgery evaluation for open, angulated, or displaced fractures; dislocations that cannot be reduced; or neurovascular compromise.
●Expose the extremity completely before the splint is applied. Clean, repair, and dress skin lesions before applying the splint.
●Take into account the patient's ability to remove his or her clothing with the splint in place before applying the splint.
●Ensure adequate and comfortable immobilization:
•Make sure that splints are of appropriate size, weight, and shape. In children, make the plaster or fiberglass slab wide enough to cover approximately one-half of the circumference of the extremity in children; do not allow the edges to overlap.
In adults, use 2 inch splinting material for finger splints; 3 and 4 inch widths for upper extremity splints; and 5 to 6 inch widths for lower extremity splinting.
•Prevention of skin breakdown by the use of proper padding is vitally important. Pad the heels, elbows, and all bony prominences adequately; place padding between the digits to prevent maceration; place extra padding over the fracture site.
•Immobilize the joints above and below a fracture unless this is not possible (such as for distal fractures below the elbow or knee).
•For a dislocated joint, immobilize the bones above and below a dislocated joint unless this is not possible (such as for distal fractures below the elbow or knee).
•To prevent stiffness and loss of function, splint the involved joints in their positions of function (table 1) [3]. In the hand, splint in the position of safety, which differs from the position of function, by extending the wrist 20 degrees, flex the metacarpophalangeal joints 90 degrees, and fully extend the proximal and distal interphalangeal joints (figure 1) [15].
•Never splint fractures circumferentially, particularly if the patient has impaired sensation, significant swelling, or circulatory insufficiency [3-5,7,14].
•Evaluate neurovascular status before and after application of the splint.
•Provide slings for added support or crutches to prevent weightbearing or use of the extremity. These activities may increase pain or swelling and/or cause the splint to break [12]. Most children can learn to use crutches by the time they are six to seven years of age.
●Provide aftercare instructions and ensure adequate follow-up:
•Instruct the patient to return to the clinician for evaluation of any numbness, tingling, or increased pain in the area underneath or distal to the splint.
•To minimize swelling, ask the patient to keep the extremity elevated, iced, and rested until reevaluation [3-7,14]. Ice is effective through the layers of Webril and Ace wrap in an area that is not covered with plaster/fiberglass. To ice the splinted extremity, place a bag of ice (or frozen vegetables) on the outside of the splint for 20 minutes. A longer duration may numb the extremity, and a shorter one may not markedly affect swelling. Place a layer of cloth or towel under the ice if the bag is too cold.
•Check splints 24 to 48 hours after application to ensure adequate fit and neurovascular integrity, evaluating for the five Ps (pallor, pain, paresthesia, pulselessness, and paralysis).
•Make sure that there is another evaluation, usually performed by an orthopedist, 7 to 10 days after injury. By this time, swelling usually has resolved and a cast can be applied if one is indicated. A cast provides longer lasting support and immobilization for the treatment of fractures. Initiate physical therapy (if indicated) after splinting, so as to prevent "freezing" or contracture of the joints.
COMPLICATIONS OF SPLINTING — Complications rarely occur when splints are applied correctly and maintained properly by the patient.
Complications include sores, abrasions, and infections from loose or ill-fitting splints; neurovascular compromise from tight-fitting splints; contact dermatitis; pressure sores; and thermal burns (from heat released during setting of plaster) [1,2,12,13,16]. Most of these complications can be avoided through careful application of the splint and monitoring of the patient's neurovascular status.
SPLINT APPLICATION — The type of splint varies depending upon the site of the injury. The most basic splint is composed of a layer of stockinette, with or without padding, and several layers of plaster (or pre-padded fiberglass) that are molded to provide comfort, support, and immobilization (picture 2). Wrap additional padding for bulk and a final layer of cotton or elastic bandage around the plaster or fiberglass to hold everything in place [1,3-7,13]. Do not wrap the final layer too tightly. Secure the bandage with tape rather than pins to prevent injuries from pins.
Customized plaster splints — Customized plaster splints may be manufactured to remain in place or to be removable.
The application of plaster splints designed to remain in place requires the following steps [13]:
●If the optional stockinette is to be used, stretch and smooth it over the extremity; extend the stockinette beyond the proximal and distal edges of the area to be splinted.
●Wrap cotton bandage (eg, Webril) around the extremity in a distal to proximal fashion; overlap each turn to cover the previous one by 50 percent. Be careful to avoid wrinkles because they can create pressure points. Extend the padding 2 to 3 cm beyond the area to be splinted. If stockinette has been used, extend it beyond the proximal and distal edges of the cotton bandage.
●Measure the plaster strips and cut to length. Cut the strips slightly longer than necessary so they can be folded back on themselves to create a smooth edge and to permit contraction of the plaster as it crystallizes [12]. Use approximately 8 to 10 layers for an upper extremity splint and 12 to 14 layers for a lower extremity splint. The risk of thermal injury is directly related to the number of plaster layers and the adequacy of padding.
●Immerse the plaster in water at room-temperature and then place it on an open towel to remove excess water and smooth the plaster.
●Apply the plaster to the extremity, molding it to the extremity
●Before the plaster hardens, fold back the proximal and distal ends over themselves to form a smooth edge; if stockinette was used, fold it over the edge of the plaster.
●Apply an (optional) layer of cast padding over the splint to prevent the plaster from sticking to the elastic bandage of the final layer or apply the elastic bandage (Ace wrap) directly to the splint.
●Wrap an elastic bandage around the extremity, distal to proximal, to secure the plaster to the extremity. Keep the limb in the desired position until the plaster hardens.
Removable plaster splints are manufactured as follows:
●Cut a piece of stockinette slightly longer than the desired length of the splint.
●Measure the plaster strips and cut or fold to length. Use approximately 8 to 10 layers for an upper extremity splint and 12 to 14 layers for a lower extremity splint.
●Tear two pieces of cast padding (eg, Webril) slightly longer and wider than the plaster strips.
●Immerse the plaster in water at room-temperature and then place it on an open towel to remove excess water and smooth the plaster.
●Place the plaster between the two strips of cast padding and place inside the stockinette (picture 2).
●Apply the removable plaster splint to the desired area and secure with an elastic bandage as described above.
●After the plaster has hardened, rewrap the elastic bandage to provide snug but not constrictive tension.
Fiberglass splints — Follow the manufacturer's instructions for application when using prefabricated splints [12]. Before proceeding, assess the patient for a history of hypersensitivity to fiberglass.
The following steps typically are included:
●If the optional stockinette is to be used, stretch and smooth it over the extremity; extend the stockinette beyond the proximal and distal edges of the area to be splinted.
●Cut the fiberglass splint to the proper length (eg, slightly longer than necessary so it can be folded back on itself to create a smooth edge).
●Immerse the fiberglass splint in room-temperature water and then place it on an open towel and roll it up inside the towel to remove excess water.
●Apply the fiberglass splint to the extremity and mold it to the desired shape; stretch the padding material over the proximal and distal edges of the splint to prevent sharp edges.
●Apply an elastic bandage to provide snug but not constrictive tension.
UPPER EXTREMITY SPLINTS — The style of splint varies depending upon the injury (table 2) [17].
Many hand injuries do not actually require immediate surgical attention and can be treated through immobilization until definitive treatment is scheduled. In the case of sports-induced hand injuries, the athlete may be able to complete the athletic season with appropriate casting and splinting measures to ensure protection of the injured player and the other competitors without causing loss of game time [18].
Sling and swathe splint — Use the sling and swathe splint primarily for shoulder and humeral injuries. The sling supports the weight of the arm and the swathe holds the arm against the chest to minimize shoulder motion. Commercial models are available, but a simple sling with a 6 inch elastic bandage will do. Place a powdered pad in the axilla before the splint is applied to prevent maceration (figure 2).
Velpeau bandage — The Velpeau bandage is another splint that is used for shoulder and humeral injuries. It is similar to the sling and swathe splint, except that the hand is held higher and the forearm lies against the chest (figure 3). The decision to use the sling and swathe splint or the Velpeau bandage is based upon the patient's comfort.
Sugar tong splints — Use the sugar tong splint to treat humeral shaft, forearm, and wrist fractures and apply according to the area involved. Sugar tong splints are also used by orthopedic specialists to maintain initial reduction of pediatric forearm fractures followed by casting at the initial follow-up visit [19]. (See "Midshaft forearm fractures in children", section on 'Definitive care' and "Distal forearm fractures in children: Initial management", section on 'Initial fracture management'.)
●Use the proximal sugar tong splint for humeral fractures. Apply the plaster from the axilla around the elbow and up the arm on the other side to the level of the axilla (figure 4).
●Use the distal sugar tong splint, also called the forearm sugar tong splint, for wrist and distal forearm fractures [20]. It extends from the metacarpophalangeal joints on the dorsum of the hand along the forearm, wrapping around the elbow back to the volar aspect of the midpalmar crease (figure 5) [5]. The distal sugar tong splint immobilizes the elbow, forearm, and wrist. Assess finger motion to prevent finger stiffness.
●Use the double sugar tong splint for elbow and forearm fractures because it limits flexion/extension at the elbow as well as pronation/supination. It is a combination of the proximal and distal sugar tong splints. The double sugar tong splint has been shown to be comparable in maintenance of reduction for distal radius and distal radius and ulna fractures [21]
●Use the reverse sugar tong splint for forearm and Colles fractures because it provides good distal support and better dorsal and ventral support than the Colles or volar splints (see 'Colles splint' below). The reverse sugar tong splint wraps around the hand and between the thumb and fingers instead of around the elbow.
Long arm splint — Use the long arm splint (or posterior splint) for stable injuries of the elbow area or forearm. Use it also to temporarily stabilize intraarticular fractures of the humerus, olecranon, or radial head in patients awaiting surgical procedures [6].
The long arm splint is a long posterior splint from above the elbow to the midpalmar crease. Apply it posteriorly to the arm, elbow, and forearm up to the wrist, with the elbow flexed at a 90 degree angle (figure 6). Apply extra strips of plaster across the joint for further reinforcement. Because the long arm splint permits pronation and supination, do not use it for complex or unstable distal forearm fractures. Double sugar-tong splints are better for these injuries.
Colles splint — Use the Colles splint to provide volar support (figure 7). Use it for fractures of the second to fifth metacarpals and distal forearm and wrist fractures as an alternative to the distal or reverse sugar tong splints. The reverse sugar tong splint offers more dorsal and ventral support and is used more often in younger children.
Dorsal and/or volar splint — Use the dorsal and/or volar short arm splint for carpal tunnel syndrome, soft tissue injuries of the hand, and fractures or injuries of the wrist. Apply it from the midpalmar crease almost to the elbow, dorsally and/or ventrally (figure 8). The use of dorsal and ventral splints in combination provides increased stability. Do not use this splint for distal forearm fractures because it permits pronation/supination. (See "Carpal tunnel syndrome: Treatment and prognosis", section on 'Wrist splinting'.)
Gutter splint — Use gutter splints primarily for phalangeal and metacarpal fractures. Radial gutter splints, with a hole cut before application, through which the thumb can pass, may also have a role in adults with distal forearm fractures, although evidence is limited to one small trial [20].
These splints extend from the proximal forearm to beyond the distal interphalangeal joint and can be radial (immobilizing the index and long fingers) or ulnar (immobilizing the ring and little fingers, also called the boxer splint). Make sure that the splint is wide enough to surround both fingers and the wrist.
In order to avoid finger stiffness, splint the fingers with the metacarpophalangeal joints in 70 degrees flexion, the proximal interphalangeal (PIP) joint in 20 to 30 degrees of flexion, and the distal interphalangeal (DIP) joint in no more than 5 to 10 degrees of flexion (figure 9). Place wadding between the fingers before application of the splint to prevent skin irritation and break down [6].
Thumb spica splint — The thumb spica splint is a variation on the gutter splint, used for scaphoid fractures and extra-articular fractures of the thumb metacarpal or ulnar collateral ligament injuries (ie, gamekeeper's thumb or skier's thumb) [5,12]. Place the splint on the radial aspect of the forearm, wrapping the thumb up to the distal interphalangeal joint (figure 10). (See "Ulnar collateral ligament injury (gamekeeper's or skier's thumb)".)
Finger splints — Splinting varies according to the type of finger injury:
●A transverse, oblique, or avulsion fracture of the proximal phalanx that is nondisplaced, is not angulated, and appears stable can be treated by buddy taping the injured finger to an adjacent finger. If the ring finger is involved, it should be buddy taped to the little finger (picture 3). Alternatively, if there is significant pain or swelling, a splint such as a gutter (figure 9) or Burkhalter (picture 4) may be used for increased comfort and stability. (See "Proximal phalanx fractures".)
●Nondisplaced stable fractures of the middle phalanx without angulation are treated by buddy taping them to an adjacent finger (picture 3). If the ring finger is involved, it should be buddy taped to the little finger. Short-term immobilization with a dorsal (picture 5) or volar finger splint (picture 6) or a toad splint (picture 7) can be used for added protection or pain control (see "Middle phalanx fractures"). Stable dorsal dislocation injuries of the PIP joint with volar plate injury should be splinted in the neutral position (as opposed to 30 degrees of flexion) to maximize functionality outcome. (See "Middle phalanx fractures", section on 'Volar plate avulsion fractures'.)
●Nondisplaced distal phalanx fractures should be splinted with the DIP joint in extension. The splint should extend past the tip of the distal phalanx to protect it from injury (picture 8). (See "Distal phalanx fractures".)
Immobilization of digit dislocations, jersey finger, and mallet deformity is discussed separately. (See "Digit dislocation reduction" and "Flexor tendon injury of the distal interphalangeal joint (jersey finger)" and "Extensor tendon injury of the distal interphalangeal joint (mallet finger)".)
Bulky hand compression dressing — Use a bulky hand compression dressing for closed hand fractures. This dressing provides bulky compression and minimizes edema. Wrap Kerlix gauze around the hand after cotton fluffs are placed between the fingers. Add a dorsal or volar splint for wrist immobilization. Wrap an elastic bandage around the hand.
Figure-of-eight splint — Although a simple sling is often used for clavicle fractures, the figure-of-eight splint may be useful in selected fractures of the middle two-thirds of the clavicle. Apply this splint while the patient is erect, with the hands on the iliac crests and the shoulders held in abduction. Wrap a stockinette or padding snugly around both shoulders (figure 11). A premade version of this splint is available.
Initial nonoperative treatment of fractures of the middle third of the clavicle is discussed in greater detail separately. (See "Clavicle fractures", section on 'Initial nonoperative treatment'.)
LOWER EXTREMITY SPLINTS — The style of splint varies depending upon the injury (table 3) [17].
Knee splint — Ready-made splints are available and usually used for knee injuries and proximal fractures of the tibia and fibula. Reserve the splint described here for patients who are too large for ready-made splints. With the knee placed in full extension, extend 6 inch plaster rolls from the buttocks posteriorly to 3 inches (7.5 cm) above the malleoli (figure 12).
Jones compression dressing — Use the Jones compression dressing splint for knee and calf injuries. Wrap the entire leg in wadding, then cotton padding followed by elastic wrap. Apply plaster splints to the medial, lateral, and posterior aspect of the knee.
Posterior leg splint — Use the posterior leg (or ankle) splint for distal leg, ankle, tarsal, and metatarsal fractures, reduced dislocations, and severe sprains. Place a plaster splint from the metatarsal heads to the fibular neck (figure 13 and picture 9) [5]. Keep the fibular neck and head free to avoid compression of the peroneal nerves. Provide crutches for patients with this type of splint (if they are able to use them), because the splint is not strong enough at the ankle to permit weightbearing [6]. Use the posterior leg splint in combination with the stirrup splint to increase stability; the posterior splint should be applied first [12].
Stirrup splint — Apply the ankle stirrup splint, also called the ankle sugar tong splint, to prevent inversion or eversion of the ankle, and provide better immobilization that the posterior leg splint for fractures near the ankle. Use it in combination with the posterior leg splint, which should be placed first [12]. The stirrup splint is similar to the sugar tong splints described above, in which plaster is applied from below the knee and wrapped around the ankle (figure 14). Facilitate application by having the patient lie in the prone position with the knee flexed [12]. Patients with stirrup splints can bear weight 36 hours after the splint is applied.
Bulky foot compression dressing — The bulky foot compression splint is similar to the hand compression. Use it to treat calcaneal fractures and foot injuries. Place cotton fluffs between the toes, apply sheet wadding in several layers and wrap the foot with elastic bandage (picture 10). Make sure the elastic wrap is looser around the leg than the ankle, to provide a pressure gradient and facilitate drainage for edema.
Buddy taping — Use buddy taping for phalangeal fractures of the toes. Place a small sheet of wadding between the toes to prevent maceration, and secure the fractured toe to the adjacent toe with adhesive strips (picture 11).
ADDITIONAL RESOURCES — An instructional video on basic splinting techniques is available elsewhere [22].
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: How to care for your cast (The Basics)" and "Patient education: How to care for your child's cast (The Basics)" and "Patient education: Common wrist injuries (The Basics)")
●Beyond the Basics topic (see "Patient education: Cast and splint care (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●General principles – Splinting plays a major role in the management of musculoskeletal injuries, particularly those involving extremity fractures and joint dislocations. Immobilization of the extremity through splinting decreases pain and bleeding and prevents further soft tissue, vascular, or neurologic compromise. Protective splinting of hand injuries may enable athletes to return to sport while in season, deferring definitive treatment until after the season. Splinting may provide definitive treatment for some injuries. (See 'General principles' above.)
●Assess extent of injury prior to splint application – The clinician should assess for neurovascular compromise and other findings that indicate the need for prompt referral to an orthopedic surgeon (eg, displaced fracture, open fracture). (See 'Basic techniques' above.)
●Basic splinting technique – Splints should typically maintain joints in the position of function, or for finger splints, the position of safety (table 1 and figure 1). For most fractures, the splint should immobilize the joint above and the joint below the fractured bone. For most dislocations, the splint should immobilize the bone above and the bone below the reduced joint. Proper padding, correct sizing of splint materials, and reassessment of neurovascular status are important to prevent complications from splinting. (See 'Basic techniques' above.)
●Splint styles and potential indications – The tables provide potential indications for specific upper and lower extremity splints (table 2 and table 3). (See 'Upper extremity splints' above and 'Lower extremity splints' above.)
●Plaster splints – These are made from gauze that is impregnated with plaster of Paris, a powdered form of gypsum. When water is added, the gypsum recrystallizes and hardens in a heat-releasing reaction. To minimize the risk of burns, use water that is no warmer than room temperature. Plaster splints take between 2 and 8 minutes to set, but they do not reach their maximum strength for approximately 24 hours. Plaster splints are easier to mold and are less expensive than fiberglass splints. However, they are more difficult to apply and become soggy when wet. (See 'Customized plaster splints' above.)
●Fiberglass splints – These and other synthetic splints (eg, Orthoglass, OCL, and Velcro splints) usually are already padded and easier to apply. In addition, synthetic splints set more quickly and are lighter, longer wearing, and water resistant. However, they are more expensive and do not mold as well as plaster splints. (See 'Fiberglass splints' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Rana Kronfol, MD, who contributed to earlier versions of this topic review.
آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟
