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Splinting And Casting Main

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Other Names

Commonly used splints and casts[1]
  • Splinting
  • Casting
  • Plaster Splint
  • Fiberglass Cast
  • Orthoglass

Introduction

General

  • Casts and splints are orthopedic devices involving that protect and support musculoskeletal injuries
  • Various materials can be used, most commonly plaster or fiberglass, but also includes malleable aluminum, air and synthetic splinting materials
  • All patients who are placed in a splint or cast require careful monitoring to ensure proper recovery[2]
  • The joint “above and below” (or proximal and distal) to the fracture site should be immobilized when possible
    • This maintains adequate control over the fracture site
  • Generally, splints are used for acute injuries to accommodate swelling/ expansion

Terminology

  • Splints: characterized by noncircumferential immobilization
  • Casts: characterized by circumferential immobilization
  • Bivalve: Cutting the cast in long axis to allow for expansion

Purpose

  • Immobilize musculoskeletal injuries
  • Support the healing process
  • Reduce pain
  • Prevent further damage
  • Maintain bone alignment
  • Compensate for musculoskeletal weakness or fatigue

General Principles

  • Upper extremity splints should have 8-10 layers, lower extremity 10-12 layers
  • Always apply additional padding on bony prominences
  • Circumferential padding should overlap by about 50% from distal to proximal
  • Splinting/ casting is highly exothermic and they should be kept in open air while hardening to prevent thermal injury

Materials

  • Plaster of Paris
    • Messier, takes longer to harden
    • Shapes more closely to the patient while wet
    • Holds unstable reductions better
  • Fiberglass
    • Faster to harden, less messy to deal with
    • Does not shape to the patient as closely as playser

Indications

  • Fractures
  • Reduced joint dislocations
  • Sprains/ Strains
  • Tendinopathies
  • Tears
  • Postoperative or Postprocedural
  • Severe soft tissue injuries
  • Post laceration repairs

Indications of Splints

  • Acute and definitive treatment of select fractures
  • Soft tissue injuries (sprains, tendons, et)
  • Acute management of injuries waiting orthopedic intervention

Indications of Casts

  • Definitive management of simple, complex, unstable or potentially unstable fractures
  • Severe, nonacute soft tissue injuries unable to be managed with splinting

Contraindications

  • No absolute contraindications

Splinting vs Casting

Advantages of splinting

  • Faster, easier to apply than casts
  • Allows for swelling because it is noncircumferential
  • Reduced risk of pressure-related complications
  • Generally considered the preferred method of immobilization in acute setting[3]
  • Commercial splints available and appropriate for select injuries
  • May be static (preventing motion) or dynamic (functional, assisting with controlled motion)

Disadvantages of Splinting

  • Lack of patient compliance
  • Increased or excessive motion at site of injury
  • Non-definitive for fractures that require prolonged immobilization

Advantages of Casting

  • Primary form of immobilization for many fractures
  • Provides more effective immobilization

Disadvantages of Casting

  • Requires more time and skill to apply
  • Higher risk of complications if not applied properly[4]

Splinting and Casting Tables

Upper Extremity Splinting and Casting Table[1]
Region Type of splint/cast Indications Pearls/pitfalls
Ulnar side of hand Ulnar gutter splint,
Ulnar gutter cast
- Fourth and fifth proximal/middle phalangeal shaft fractures,
- Select metacarpal fractures
Proper positioning of MCP
joints at 70 to 90 degrees of
flexion, PIP and DIP joints at
5 to 10 degrees of flexion
Radial side
of hand
Radial gutter splint,
Radial gutter cast
- Second and third proximal/ middle phalangeal shaft fractures,
- Select metacarpal fractures
Proper positioning of MCP
joints at 70 to 90 degrees of
flexion, PIP and DIP joints at
5 to 10 degrees of flexion
Thumb, first
metacarpal,
and carpal
bones
Thumb spica splint,
Thumb spica cast
- Injuries to scaphoid/trapezium
- Nondisplaced, nonangulated, extra-articular first metacarpal fractures
- Stable thumb fractures with or without closed reduction
Fracture of the middle/
proximal one third of the
scaphoid treated with
casting
Finger injuries Buddy taping - Nondisplaced proximal/middle phalangeal shaft fracture
- Finger sprains
Encourage active range
of motion in all joints
Aluminum U shaped splint - Distal phalangeal fracture Encourage active range
of motion at PIP and MCP
joints
Dorsal extension block splint - Middle phalangeal volar plate avulsions
- Stable reduced PIP joint dislocations
Increase flexion by 15 degrees
weekly, from 45 degrees to
full extension
Buddy taping permitted with
splint use
Mallet finger splint - Extensor tendon avulsion from the base of the distal phalanx Continuous extension in the
splint for six to eight weeks
is essential
Wrist/hand Volar forearm splint,
Dorsal forearm splint
- Soft tissue injuries to hand and wrist
- Carpal bone fractures (excluding scaphoid/trapezium)
- Distal Radius Fracture: Childhood buckle
Consider splinting as
definitive treatment for
buckle fractures
Short arm cast - Distal Radius Fractures: Nondisplaced, minimally displaced, or buckle
- Carpal bone fractures other than scaphoid/trapezium
Forearm Sugar Tong Splint - Distal radius fracture,
- Distal ulna fracture
Used for increased
immobilization of forearm
and greater stability
Elbow,
proximal
forearm, and
skeletally
immature
wrist injuries
Long arm posterior splint,
Long arm cast
- Distal Humerus Fracture
- Proximal/midshaft forearm fractures
- Nonbuckle wrist fractures
Ensure adequate padding
at bony prominences
Double sugar tong splint - Acute elbow and forearm fractures
- Nondisplaced, extra-articular Colles Fracture
Offers greater immobilization
against pronation/supination
Lower Extremity Splinting and Casting Table[1]
Region Type of splint/cast Indications Pearls/pitfalls
Ankle Posterior ankle splint - Severe sprains
- Isolated, nondisplaced malleolar fractures
- Acute foot fractures
Splint ends 2 inches distal to fibular head to avoid common peroneal nerve compression
Ankle Stirrup splint - Ankle sprains
- Isolated, nondisplaced malleolar fractures
Mold to site of injury for effective compression
Lower leg,
ankle,
and foot
Short leg cast - Isolated, nondisplaced malleolar fractures
- Tarsal fractures
- Metatarsal fracture
Compartment syndrome most commonly associated with proximal mid-tibial fractures, so care is taken not to over-compress Weight-bearing status important; initially non–weight bearing with tibial injuries
Knee and
lower leg
Posterior knee splint - Acute soft tissue and bony injuries of the lower extremity If ankle immobilization is necessary, as with tibial shaft injuries, the splint should extend to include the metatarsals
Foot Short leg cast with toe plate extension - Distal metatarsal fracture
- Distal phalangeal toe fractures
Useful technique for toe immobilization Often used when high-top walking boots are not available

Materials

Common splinting materials. Top row from left to right: stockinette, web roll, plaster of paris and fiberglass cast material. Bottom row elastic wrap, tape, scissors, and gloves[5]

General Materials

  • Stockinette
    • Cloth sleeve
    • Base layer for splint/cast
    • Protects skin
  • Cast padding
    • Used with plaster of Paris
    • 2-3 layers with padding of bony points as needed
    • Wrapping circumferentially with 50% overlap will automatically create 2 layers
  • Elastic bandage
    • Outer layer to hold splints in place
    • Excessive tightness can lead to pain, less room for swelling
  • Other materials
    • Scissors or Trauma Shears
    • Lukewarm water/ bucket
    • Nonsterile gloves
  • Casting materials
    • Knife
    • Shears
    • Spreaders
    • Cast saw

Types of Casting/ Splinting Materials

  • Plaster of Paris
    • 8-10 layers for upper extremity splints, 10-15 for lower extremity splints
    • Takes 20 minutes to cure, sooner if warmer water is used
    • Watch for exothermic reaction
  • Prefabricated Fiberglass (e.g. orthoglass)
    • Pre-wrapped material
    • Use cool or room temperature water
    • Not as pliable as plaster of Paris (avoid for challenging reductions which require tight immobilization)
    • Trim or cover cut edges to prevent injury
  • Cast Fiberglass Tape
    • Used for definitive, circumferential casts
    • Malleable, dries firmly for immobilization

List of Splints


General Splinting Procedure

Illustration of the steps to apply a splint. Note the forearm volar splint is demonstrated by the steps are largely the same for any type of splint application[6]
  • Assess pre-procedure neurovascular status (i.e., distal pulse, motor, and sensation)
  • Measure and prepare the splinting material
    • Consider using contralateral limb to measure
    • Most splints use a width slightly greater than the diameter of the limb
  • Apply stockinette (if applicable)
    • Extend 2-3" beyond estimated the splinting material length
  • Apply padding
    • Use 2–3 layers over the area to be splinted / between digits (when applicable)
    • Add an extra 2–3 layers over bony prominences
  • Apply splinting material
    • Lightly moisten the splinting material
    • Place as appropriate to specific splint type
    • Once finished, if applicable fold the ends of stockinette back over the splinting material if there is excess
  • Apply elastic bandaging (e.g., ace wrap)
    • While still wet
    • May further mold the splint to the desired shape
    • Maintain position until splint material has hardened
  • Re-check and document repeat neurovascular status

List of Casts

Upper Extremity

Lower Extremity

Axial


General Cast Procedure

  • Assess pre-procedure neurovascular status (i.e., distal pulse, motor, and sensation)
  • Apply stockinette
    • Appropriate length typically 2-3 inches longer on each end
  • Apply cast padding
    • Use 2–3 layers over the area to be splinted / between digits (when applicable)
    • Add an extra 2–3 layers over bony prominences
    • Wrap circumferentially along distribution cast is going to be applied
    • Overlap the cast roll by about half to prevent any gaps
    • Smooth the material out to avoid protrusions and lumps
  • Apply cast fiberglass
    • Immerse in luke warm water and gentle squeeze excess water out
    • Apply circumferentially over area intended to be covered
    • Work either distal to proximal or proximal to istal
    • Leave about 1 inch of padding and stockinette exposed at each end
    • Apply 3-4 layers to ensure adequate immobilization, each layer overlaps by about half
    • Smooth out casting material to fill in the interstices in the plaster, conform to the contour of the limb
    • Use your palms rather than your fingertips to prevent the development of indentations
  • Fold back the stockinette
    • Do this before laying down the last layer of cast material
    • This should cover all the rough edges of the material to create a smooth edge
    • Secure the stockinette under the casting material
  • Optional: use a little hand soap over the cast material to smooth it out
  • Re-check and document repeat neurovascular status

Pearls and Pitfalls

  • Avoid large wrinkles folds with padding, can cause skin damage and breakdown
  • Apply splint firmly but not too tight
    • Allow room for anticipated swelling
    • Tight splint can lead to compartment syndrome
  • Mold splint material with palms rather than fingers to prevent ridges, may be uncomfortable for patient
  • For upper extremity splints, consider shoulder sling for comfort
  • Avoid direct content of sharp edges with skin to prevent skin breakdown
  • Apply extra padding over bony prominences

Aftercare

  • Try to elevate extremity for the first few days to prevent more swelling
  • Advise patient to keep cast or splint clean and dry
  • Do not insert objects into splint/ cast
  • Monitor for complications (worsening pain, paresthesia/ numbness, color changes)
  • Seek further care if unable to control pain at home

Removal

Illustration of cast removal[7]
Demonstration of cast removal with cast spreaders[8]
  • Demonstrate safety of cast saw by placing on your hand
  • Perform a single cut along the length of the cast
    • Draw cutting lines on cast if possible
    • Avoid bony areas, blood stained areas
  • Create a bivalve cut
    • Follow lines on each side to leave posterior slab for use as a resting splint
  • Saw technique
    • Cut with in/out motion
    • Beware blade gets hot enough to burn skin
  • Use cast spreaders to carefully separate the cast
  • Use scissors to cut the padding
  • Perform a skin exam to look for pressure injuries

Complications

Acute

  • Burns/ Thermal Injuries (from exothermic reaction)
  • Acute Compartment Syndrome
  • Compressive ischemia
  • Dermatitis
  • Deep Vein Thrombosis
  • Peripheral nerve injury
  • Pressure ulcer, skin breakdown
  • Note: these complications can occur regardless of how long the device is used[9]

Subacute/ Chronic


See Also

Internal

External


References

  1. 1.0 1.1 1.2 Boyd, Anne S., Holly J. Benjamin, and Chad A. Asplund. "Splints and casts: indications and methods." American family physician 80.5 (2009): 491-499.
  2. Benjamin HJ, Mjannes JM, Hang BT. Getting a grasp on hand injuries in young athletes. Contemp Pediatr. 2008;25(3):49-63.
  3. Eiff MP, Hatch R, Calmbach WL, eds. Fracture Management for Primary Care. 2nd ed. Philadelphia, Pa.: Saunders; 2003:1–39.
  4. Simon RR, Koenigsknecht SJ, eds. Emergency Orthopedics: The Extremities. Norwalk, Conn.: Appleton and Lange; 1995:3–20.
  5. Ganti, Latha, ed. Atlas of emergency medicine procedures. Springer Nature, 2022.
  6. Image courtesy of EMRA.org, "Splinting Tehniques"
  7. Image courtesy of NHS, "Practical Guide to Casting"
  8. Image courtesy of https://www.aquacastliner.com/
  9. General principles. In: Simon RR, Sherman SC, Koenigsknecht SJ, eds. Emergency Orthopedics: The Extremities. 5th ed. New York, NY: McGraw-Hill; 2007:1-29.
  10. Boyd AS, Benjamin HJ, Asplund C. Principles of casting and splinting. Am Fam Physician. 2009;79(1):16-22.
Created by:
John Kiel on 26 May 2023 10:04:02
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Last edited:
6 May 2024 00:08:22
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