SPLINTING

 

 

INDICATIONS:

Temporary immobilization to improve pain and discomfort, decrease blood loss, reduce the risk for fat emboli and minimize the potential for further neurovascular injury associated with:

·         Fractures

·         Sprains

·         reduced dislocations

·         tendon lacerations

·         deep lacerations across joints

·         painful joints associated with imflammatory disorders

 

 

CONTRAINDICATIONS:

 

 

MATERIALS:

• Plaster Rolls or sheets
• Strips or rolls of various width made from crinoline-type material impregnated with plaster which crystallizes or “sets” when water is added
• Prefabricated Splint Rolls (Ortho-Glass)
• Layers of fiberglass between  polypropylene padding
• Stockinette
• Cast padding
• Elastic bandages
• Adhesive tape
• Heavy scissors
• Bucket
• Protective sheets or pads to protect patient clothing
• gloves

 

 

PATIENT EDUCATION:

• Instructions should be both verbal and written
• Explain and demonstrate the importance of elevation to minimize swelling and decrease pain
• Apply ice bags or cold packs (bags of frozen vegetables also work well) for at least 30 minutes at a time during the first 24-48 hours after injury to decrease swelling and pain
• Avoid getting the splint wet – some splints may be removable for bathing purposes, otherwise plastic bags may be placed over the splint to keep it dry while bathing
• Explain signs of infection and vascular compromise, instruct patient to seek help for any concerns
• Instruct patient to return for evaluation of damaged/broken or wet splint
• Discuss follow-up guidelines

 

 

PROCEDURE/TECHNIQUE:

• Prepare the patient
• Cover patient with sheet or gown to protect clothing
• Inspect skin for wounds and soft tissue injuries
• Clean, repair and dress wounds as usual prior to splint application
• Padding
• Apply stockinette to extremity to extend several cm beyond edges of plaster, so that it may be folded back over the edges of the splint after plaster is applied to create a smooth edge
• Roll on two to three layers of cast padding evenly and smoothly (but not too tight) over the area to be splinted.
• Extend the padding out beyond the planned area to be splinted so that it can be folded back with the stockinette over the edges of plaster to create smooth edges.
• Each turn of the webril/cast padding should overlap the previous by 25-50 % of its width.
• Place extra padding over bony prominences to decrease chance of creating pressure sores
• An alternative to circumferential stockinette and cast padding is to place 2-3 layers of padding directly over wet plaster, and then apply this webril-lined splint over the area to be immobilized and secure it with an elastic bandage
• Prepare the plaster splint material
• Ideal length and width of plaster depends on body part to be immobilized in the splint
• Estimate the length by laying the dry splint next to the area to be splinted
• Be generous in estimating length, the ends can always be trimmed or folded back
• Width should be slightly greater  than the diameter of the limb to be immobilized
• Cut or tear the splint material to the desired length
• Choose thickness based on body part to be immobilized, patient body habitus, and desired strength of splint
• Average of 8-12 layers
• Less layers (8-10) for upper extremities
• More layers (12-15) for lower extremities
• More layers may be needed for large patients
• Fill a bucket with cool water, deep enough to immerse the splint material into
• Using cool water decreases the chances of thermal burns, but takes longer for the splint to dry
• Application of the splint
• Submerge the dry splint material in the bucket of water until bubbling stops
• Remove splint material  and gently squeeze out the excess water until plaster is wet and sloppy
• Smooth out the splint to remove any wrinkles and laminate all layers
• Place the splint over the webril cast padding and smooth it onto the extremity
• An assistant (or a cooperative and willing patient) may be required to hold the splint in place while you adjust the splint
• Fold back the edges of the stockinette and cast padding over the ends of the splint
• Secure the splint with an elastic bandage
• Place the extremity in the desired position and mold the splint to the contour of the extremity using the palms of your hand.  (Avoid using your fingers to mold in order to decrease indentations in the plaster which can lead to pressure sores)
• Hold the splint in the desired position until it hardens
• Check and finish the splint
• Check for vascular compromise
• Check for discomfort or pressure points
• Apply tape along the sides of the splint to prevent elastic bandages from rolling or slipping, (avoid circumferential tape to allow for swelling)
• Provide sling or crutches as needed

               

**See Diagrams for specific splints

 

 

COMPLICATIONS, Prevention & Management:

 

Compartment Syndrome

• Usually less common in splints than with circumferential casts
• may occur associated with splints from constricting webril (cast padding) or elastic bandages that cause increased pressure within a closed space on an extremity
• increased pressure leads to inadequate tissue perfusion and loss of tissue (muscle, vascular and nerve) function within the compartment. 
• Presenting signs and symptoms:  (The “5 P’s” are pathognomonic for ischemia:  pain, pallor, paresthesias, paralysis, and pulselessness, but seldom all occur simultaneously, and when they do – indicate a late finding associated with poor prognosis). 

·         pain in the extremity

·         tenderness over the involved compartment

·         significant pain with passive stretching of ischemic muscle tissue

·         diminished distal pulses and sensation

·         delayed capillary refill, and pale cool skin. 

 

Prevention

·         avoid wrapping bandages too tightly or making circumferential splints

·         elevate the extremity to decrease swelling

·         apply topical cold packs

·         no weight bearing

·         early (24-48 hour) follow-up for high-risk injuries

 

Management

·         remove all constricting bandages and splint materials

·         consider compartment pressure monitoring

·         early consultation with orthopedist and/or vascular surgeon for possible fasciotomy

 

Pressure Sores

• Uncommon with short term splinting
• Can result from stockinette wrinkles, irregular wadding of padding, insufficient padding over bony prominences or indentions in plaster form using fingers to mold splint
• If suspected, remove the splint materials and check the skin carefully, care for wounds and revise the splint if necessary

 

Heat Injury

• can result from drying plaster which produces heat and may cause burns to underlying skin
• To reduce risk for thermal injury, use cool water to wet the splint material and keep splint thickness less than 12 sheets of plaster

 

Infection

• More common with open wounds, but may occur with intact skin
• Clean and debride wounds well prior to splint application
• Consider using a removable splint for periodic wound checks

 

Joint Stiffness

• Expected to some extent after any immobilization of a joint
• Avoid prolonged immobilization if possible

 

 

DOCUMENTATION FOR THE MEDICAL RECORD:

• Note the indication for the splint
• Describe any wounds and their location under the splint
• Document the neurovascular exam findings
• Describe the type of splint applied, area immobilized, and materials used to make the splint
• Indicate what follow-up is planned for re-assesment of injury

ITEMS FOR EVALUATION:

• Understands indications for splint
• Knowledge of different materials needed for splinting
• Ability to apply a functional splint which adequately immobilizes the intended part
• Understands potential complications and their prevention and management
• Explains procedure to patient and answers questions
• Proper documentation in the medical record