Compartment syndrome is a true orthopedic emergency, and if you don’t consider it in your differential diagnosis, it can be missed easily! Dr. Katelyn Hanson, a combined EM-IM resident at Jefferson Health, packs the presenting symptoms, causes, and definitions into this flashy infographic. (more…)
The SplintER Series is back with its second installment! In the first post, Splint 101, we discussed the indications and relative contraindications to splinting. In this post, we focus on the materials used in splinting and some key steps in splint application.
A splint consists of 3 layers:1
There are 2 types of traditional splinting material – plaster and fiberglass. Plaster allows for more malleability, whereas fiberglass is more lightweight and easier to apply. There are also prefabricated splints such as Ortho-Glass®.
To apply a splint:
Although it is important that a splint fits to the extremity, it is equally important that it is not so tight that it obstructs venous outflow. Recall that a splinted limb is at risk for compartment syndrome. Be sure to perform a neurovascular exam before and after placing a splint.
For a concise instructional summary, the EMRA Splint Guide is extremely useful.
First published in 1852 by a military surgeon named Antonius Mathijsen [2], plaster (of-Paris) has been used for over a century in order to immobilize fractures. It was the only true rigid splinting material available until the advent of fiberglass in 1987. More recently, prefabricated splints such as Ortho-Glass are available. This post focuses on the traditional method to forming a splint from plaster or fiberglass.
Given the layering and formed paste, plaster can be more difficult to apply. However, it is more malleable. Fiberglass, while less flexible, hardens quickly, is easier to apply, and is lightweight [3]. The newer prefabricated splints such as Ortho-Glass contain fiberglass and are pre-padded. Unlike traditional plaster and fiberglass, these pre-padded fiberglass splints require only a minimal amount of cool water to activate. The selection of splint material will depend on provider preference and institutional availability.
Ortho-Glass® splint material (Photo Credit: William Denq)
The use of a stockinette can be useful in protecting the skin from the sharp edges of splinting material. It prevents chafing and helps to maintain the shape of the splint. However, if the stockinette is too loose or the wrong size, the material can collect together and create pressure points, which increase the risk of skin ulceration. If the stockinette gets wet, it can cause skin maceration. Typically, a stockinette is not required for a simple splint – padding is enough to protect the skin.
Stockinette (Photo Credit: William Denq)
Padding is required for both plaster and fiberglass media. It provides a comfortable medium between the skin and rigid splint, while also preventing skin maceration [4]. Padding, like the rigid splinting material, is categorized by its width, usually 3, 4, 5, or 6 inches.
Soft padding (Photo Credit: William Denq)
Evaluate for bony prominences, and adequately pad these areas, which are prone to forming pressure sores. Examples include the olecranon, malleoli, and calcaneus [2]. Applying additional strips of padding to these areas avert the need to place an additional circumferential wrap.
Water temperature affects how fast the splinting material hardens [4]. If the water is warmer, the material will harden faster. However, the quicker the material hardens, the greater potential for a serious burn. Never use warm or hot water for plaster. Utilize cool water with fiberglass as it inherently hardens faster than plaster. Tepid water should be be used to activate plaster. Be sure to change the water you use after each splint application because the residual splint material can accelerate the activating and hardening process [2].
Use tepid or cold water for plaster or fiberglass, respectively. (Photo Credit: William Denq)
Neurovascular Exam: Before applying a splint, perform a neurovascular exam, findings should be the same before and after splint application.
| Expert: Dr. Elizabeth Delasobera | Tips on the Neurovascular Exam |
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The patient’s stockinette, padding, and splint material all need to be measured out and cut to the appropriate length.
Any wounds that are on the affected limb need to be thoroughly assessed, cleaned, and appropriately dressed prior to splint application. Avoid using tape with the dressing; instead secure it with a rolled gauze being careful to avoid excessive compression.
If splinting fingers or toes, ensure padding is placed between fingers/toes to prevent maceration. If splinting the forearm and the padding needs to traverse the thumb, create a defect in the padding to stick the thumb through.
Application of stockinette and overlying padding (Photo Credit: Caleb Sunde)
If using plaster, submerge the layers in tepid water until the bubbling stops. This signals the complete saturation of the material [3]. If using fiberglass, submerge the layers in cool water until the bubbling stops. Prefabricated splints such as Ortho-Glass should not be submerged as it only requires a minimal amount of cool water to activate the material.
The purpose of applying water to a splint material is to activate it. Doing so will cause an exothermic reaction while the material hardens. Because burns have been reported, use cooler water (as opposed to hot water), and apply generous padding. Wring out as much water as possible while still maintaining the plate-like integrity of the splint material. Place the splint on a hard surface or several layers of your pre-cut padding to smooth out any formed wrinkles.
Activating the splint by submerging in tepid water (Photo Credit: William Denq)
While keeping the extremity in its desired position, conform the material to the extremity with the palm. Fingers can create indentations and unintentional pressure points that may result in skin breakdown [4]. An assistant may be used to help stabilize the splint material onto the affected limb. To avoid accidental soft tissue damage or discomfort from the sharp ends of plaster and fiberglass, fold the edge over on itself. In general, plaster hardens in 5-10 minutes and fiberglass in 3-4 minutes.
Do NOT rest the affected extremity with a forming splint on a surface such as a pillow or table as it could trap the exothermic reaction generated and result in a burn [2].
Application of the splint over stockinette and padding (Photo Credit: Caleb Sunde)
The elastic bandage should be wrapped onto the affected extremity in a distal to proximal direction. This theoretically helps with venous return and reduces subsequent swelling from an acute injury [5]. Although the bandage application helps to conform the hardening splint material to its desired position, excessively tight application (in an effort to reduce swelling and mold the splint) may instead result in compartment syndrome.
Application of the elastic bandage should be in a distal to proximal fashion. (Photo Credit: Caleb Sunde)
After the splint application, the procedure is not yet complete.
A 3 year-old boy presents with a deep laceration of the distal phalanx, through the nail bed, after slamming his fingers in a car door. He is crying, anxious, and uncooperative. How do you make this situation easier to evaluate and repair?
Nail bed and finger laceration repairs can be challenging, and even more challenging in young patients. Preparation is key to getting a good outcome. Here we present a pediatric trick of the trade on immobilizing a finger for digit or nail bed procedures.
Atraumatic low back pain is a common complaint in the ED. For most patients, a thorough history and physical exam is sufficient to exonerate causes that threaten life or neurological function. For a small subset, however, MRI may be required. ALiEM has partnered with the ACEP E-QUAL Network to promote clinical practice improvements through a series of podcasts. In our first installment, we focus on this common presentation. We review highlights from an interview with Dr. Jonathan Edlow, Vice Chair of Emergency Medicine at Beth Israel Deaconess, about the presentation and evaluation of low back pain. Afterward be sure to check out the podcast in full.
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Why do we splint? Splinting is one of the fundamental procedures of the Emergency Department (ED). How well-versed are we with it? Why do we even splint? By the end of this post, you will know the reason why we splint, when to splint, and just as importantly — when NOT to splint in the ED.
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The purpose of the SplintER series is to teach the fundamentals and introduce advanced concepts of splinting to the Emergency Medicine (EM) professional. Humans have been splinting their injuries since 1300 B.C.1 Although the fundamentals have not changed, splint selection and application require some thoughtful consideration. A 2017 prospective, observational study in the Journal of Pediatric Orthopaedics demonstrated that more than 90% of splints applied in the Emergency Department were inappropriate (30% applied by EM attendings), as evaluated by orthopaedic surgeons.2 While that number may not be representative in your institution, it certainly highlights the inadequacies that many of us feel when approaching a splint!
A young man is brought into an emergency department after an electric lawn edger cut through his work boot and into the dorsum of his right foot. He has a clearly contaminated 5 cm x 1 cm laceration on the lateral side, and an underlying tendon is exposed. Sensation is diminished around the wound and he is unable to actively extend his 5th toe past a neutral position. How would you diagnose and repair his extensor tendon injury?
