Splinting-Techniques

1. Author: Joel Moktar (MD)
Splinting Techniques

2. Learning Objectives
 To understand the indications and contraindications
for basic splinting
 To learn the basic equipment necessary for splinting
 To understand the technique of splinting
 To learn the possible complications of splinting
 To provide sources for further information

3. Indications
 Fractures
 Sprains
 Dislocations
 Joint infections
 Acute arthritis or gout

4. Indications
 Stabilize acute injuries, lessen pain and aid healing
 Reduces the chance of compartment syndrome
development compared to circumferential casts and
are easier to apply
 Casts provide better immobilization and can maintain
reduction of displaced fractures, but higher rates of
complications

5. Contraindications
 No absolute contraindications
 Relative contraindications
 Risk of significant increased swelling
 Neurovascular compromise
 Open fractures – urgent surgical consult required
 Significant soft tissue injuries

6. Equipment
 Stockinette
 Thin layer to protect skin
 Cut long to extend past edges of split
 Soft Roll (Webril Padding)
 Layer of soft padding
 Select size appropriate for circumference

7. Equipment
 Plaster of Paris
 Approximately 10 sheets of rectangular plaster
 Requires soaking in room-temperature water
 Other materials: scissors, gloves, tape, sheets
 Will require preparation: plaster is measured and cut
to appropriate size, soaked in water and wrung
 Alternative options:
 Pre-fabricated slabs
 Fiberglass

8. Basic technique
 Ultimately, the goal of splinting in fracture
management is to immobilize fractures in
acceptable position to aid healing, and to
obtain and maintain an adequate
reduction for displaced fractures

9. Basic Technique
 Examples of splinting procedures
Splint Type Upper Extremity Injury
Sugar Tong Humeral shaft fracture
Volar Forearm Distal radius, Carpal bone fractures excluding scaphoid &
trapezium
Ulnar Gutter Fractures of the 4th
or 5th
metacarpal and boxer's
fractures
Thumb Spica Scaphoid fractures, snuffbox tenderness, extra-articular
fracture of 1st
metacarpal

10. Basic Technique
 Wide variety of splinting procedures
Splint Type Lower Extremity Injury
Posterior Slab Malleolar, talar and calcaneal fractures
Above Knee Patellar tendon rupture, if other methods unavailable, tibial
plateau fractures

11. Basic Technique
 ATLS protocol - ensure patient is stable
 Expose injured area
 Detailed neurovascular exam proximal and
distal to injury, before and after splinting
 Consult Orthopaedics for open fractures or
for assistance for splinting where required
(unstable fractures, candidates for operative
management)

12. Basic Technique
 Prepare materials
 Select appropriate stockinette size
 Cut such that it extends past exposed injured
area
 Select appropriate soft roll (outer layer) size
 Measure the length of plaster needed
 Fill a bucket with room temperature water

13. Case
 A 45 year old man is brought into the ER
after slipping at work. He is medically
stable, but is holding his right wrist in pain.
He states he fell forward onto his
outstretched hand. An x-ray reveals a
displaced fracture of his distal radius
(Colles fracture).

15. Basic Technique: Case 1
 Colles Fracture: Volar splint
 Immobilizes wrist and prevents forearm pronation/supination
 Plaster extends from MCP joints to proximal forearm
 MCPJs and elbow remain able to flex/extend in cast
 Resource: NEJM splinting video

16. Basic Technique: Volar splint
Boyd A, Benjamin H and Asplund. C. Splints and Casts: Indications and Methods. American Family
Physician. 2009. 80: 491-499. Figure 7.

17. Basic Technique: Volar splint

18. Basic Technique: Volar splint

19. Basic Technique: Volar Splint
 Set up:
 Wrist in supination, 20-30 degrees flexion and
slight ulnar deviation
 Apply stockinette
 Unroll over arm, well past elbow
 Cut a small hole for the thumb
 Smooth out, removing wrinkles

20. Basic Technique: Volar Splint
 Apply Soft roll
 Unroll from distal to proximal
 Just past the elbow, overlapping areas by 50%
 Apply extra padding over bony prominences
 Apply plaster
 Soak 10 sheets of plaster in warm water
 Plaster leaves MCPs and elbow free
 Smooth out the plaster

21. Basic Technique: Volar Splint
 Molding:
 3 point molding to
maintain reduction
 Wrist should be in
full pronation, with
slight ulnar
deviation flexion

22. Case 2
 A patient presents to the ED after an
argument with his girlfriend the previous
evening in which he lost his temper and
punched a wall. He is tender over the
dorsal right 5th
MCP joint and distal
metacarpal. There is no laceration
overlying the dorsal hand. An x-ray is
obtained.

24. Boxer’s Fracture

25. Basic Technique: Ulnar Gutter
 Indication:
 Fractures of the 4th
and 5th
metacarpals, “Boxer’s fracture”
 Technique:
 Wrist is held in slight extension and the 4th
and 5th
MCP joints in
mid-flexion (70-90º),
 Stockinette and soft roll extend distally to elbow then folded back
 Plaster extends along the ulnar side of the mid-forearm to the 4th
and 5th
DIP joints, with plaster wrapping around these fingers
 Additional soft roll & elastic bandage to cover plaster

26. Basic Technique: Ulnar Gutter
Boyd A, Benjamin H and Asplund. C. Splints and Casts: Indications and Methods. American Family
Physician. 2009. 80: 491-499. Figure 1.

27. Basic Technique: Thumb Spica
 Indication:
 Nondisplaced distal scaphoid fracture (suspected/occult or
visualized on x-ray), extra-articular fracture of 1st
metacarpal
 Technique:
 The wrist is slightly extended and the thumb in functional
position (“holding a beer can”)
 Stockinette and soft roll extend distally to elbow
 Plaster extends along the radial aspect of the distal 2/3rds of
forearm to wrapping around the thumb up to the IP joint
 Soft roll & elastic bandage to cover plaster

28. Basic Technique: Thumb Spica
Boyd A, Benjamin H and Asplund. C. Splints and Casts: Indications and Methods. American Family
Physician. 2009. 80: 491-499. Figure 2.

29. Basic Technique: Posterior Ankle Splint
 Indication:
 Malleolar, talar, calcaneal fractures and Achilles tendon tears
 Technique:
 Patient prone, ankle is in 90º flexion
 For Achilles tear, ankle is immobilized in plantar flexion
 Stockinette and soft roll extend just distal to knee
 Plaster extends from the MTPs along the plantar aspect of
the foot, ankle and posterior calf ending 2 inches distal to the
posterior knee

30. Basic Technique: Posterior Ankle Splint
Boyd A, Benjamin H and Asplund. C. Splints and
Casts: Indications and Methods. American Family
Physician. 2009. 80: 491-499. Online Figure G.
Note: Ankle fractures should be
treated with a three sided splint
(ie: Posterior Ankle + Stirrup)

31. Basic Technique: Stirrup Splint
 Indication:
 Malleolar, talar and calcaneal fractures
 Technique:
 The ankle is in 90º flexion
 Stockinette and soft roll extend just distal to knee
 Plaster extends from the lateral aspect of the mid-calf around
the heel to the medial aspect of the mid-calf.
 Similar to sugar-tong splint
 Additional soft roll and elastic bandage for stabilization

32. Basic Technique: Stirrup Splint
Boyd A, Benjamin H and Asplund. C.
Splints and Casts: Indications and
Methods. American Family Physician.
2009. 80: 491-499. Online Figure H.
Note: Ankle fractures
should be treated with
a three sided splint
(ie: Posterior Ankle +
Stirrup)

33. Trouble-shooting
 Water should be warm
 Too cold – requires a longer set time
 Too hot – increased risk of thermal injuries
 Smooth out wrinkles or creases in plaster to
reduce risk of pressure sores
 Ensure adequate soft roll coverage over bony
prominences
 Distal neurovascular exam before and after
casting

34. Complications
 Thermal injuries: Plaster setting is an exothermic reaction,
ensure the water used to soak the plaster is warm
 Pressure sores: Caused by uneven plaster, wrinkles or
creases. Ensure adequate soft roll over bony prominences
and smooth out the plaster as it sets
 Compartment syndrome, less likely with splints than casts
 To avoid, ensure injured area has enough room to swell
 If compartment syndrome occurs, immediately remove splint
 Assess limb for ischemic injury
 Lack of stability and re-injury from poor immobilization

35. Case 1, revisited
 Your patient has a volar splint applied for
their Colle’s fracture. However, he returns
several days later complaining of pain and
irritation in the area of his ulnar styloid.
Upon inspection you find a depression in
the plaster material and the bony
prominence is only covered by one layer of
soft roll.

36. Case 1, revisited
 Resolution: Pressure sores by result from creases or
folds in plaster material or inadequate soft roll
coverage, often over bony prominences
 Ensure several layers of soft roll cover areas of bony
prominence
 Ensure the plaster is smoothed out and immobilized
until it is fully set to avoid creases

37. Links to Procedural Videos
NEJM splinting video:
http://www.nejm.org/doi/full/10.1056/NEJMvcm0801942
Ulnar gutter splint:
http://www.youtube.com/watch?v=kx2YBmq7oS0
Thumb spica splint:
http://www.youtube.com/watch?v=864h9gVgmKs

38. Quiz Question 1
 When compared to casts, splints:
 A. Better reduce immobilization injuries
 B. Provide superior stability
 C. Reduce compartment syndrome
 D. More difficult to apply

39. Quiz Question 2
 A patient in the ED has an open fracture of his fibula. You
should:
 A. Splint the fracture to prevent compartment syndrome
 B. Apply a circumferential leg cast
 C. Consult orthopaedic surgery
 D. Apply a tensor bandage

40. Quiz Question 3
 For a displaced fracture of the distal radius,
the most appropriate splint to apply is:
 A. Sugar tong splint
 B. Volar slab
 C. Radial gutter splint
 D. Short arm cast

41. Quiz Question 4
 You assess a patient in the ED who has recently
punched a wall during a fight. X-rays show a fracture
of the distal fifth metacarpal, also known as a Boxer’s
fracture. The most appropriate splint to apply is:
 A. Volar forearm splint
 B. Radial gutter splint
 C. Thumb spica splint
 D. Ulnar gutter splint

42. Quiz Question 5
 Good splinting technique does not include which of
the following:
 A. The plaster is soaked in hot water
 B. Stockinette that extends past the area to be splinted
 C. Soft roll coverage, especially over bony prominences
 D. Wrinkles and creases are smoothed out as the plaster
sets

43. Summary
 Splinting is effective for acute management of bony
injuries (fractures) and some soft tissue injuries
 The primary advantage of splinting over
circumferential casts is that they allow for acute
swelling and are easier to apply
 Consult Orthopedics for open fractures or those in
which reduction is not adequately obtained or not
anticipated to be maintained (unstable fractures), or
fractures involving neurovascular compromise

44. General References
 Journal Articles:
 Boyd A, Benjamin H and Asplund. C Spints and Casts: Indications and Methods. Amierican Family
Physician. 2009. 80: 491-499.
 Fitch, M et al. Videos in Clinical Medicine: Basic Splinting Techniques. NEJM. 2008.
http://www.nejm.org/doi/full/10.1056/NEJMvcm0801942
 Chapters in Textbooks:
 Simon, R and Sherman S. Emergency Orthopedics, 6th
ed. 2011. McGraw-Hill.
 AO foundation:
 https://www.aofoundation.org
 Wheeless Online: Textbook of Orthopaedics
 http://www.wheelessonline.com/
 Web Links
 http://www.nejm.org/doi/full/10.1056/NEJMvcm0801942