Injuries of the upper extremity are a common complaint seen by pediatrics residents in the emergency department, and splinting is a skill that residents receive limited training on prior to practice in a clinical setting. After surveying the current residents rotating in the ED, most residents felt a review of upper extremity splinting would be useful.
Why do I need to splint a fracture?
Limiting mobility of a fracture will decrease further injury and reduce risk of vascular and/or neurologic compromise. Splinting may also help promote healing in the correct alignment and reduce pain.
Why do we not cast frequently in the ED setting?
This is a very common question asked by parents in the ED. Splints permit swelling that will inevitably occur in the first 24-48 hours after injury, unlike casting which leaves little room for swelling. There are some occasions where a cast may be safe on day one, such a simple buckle fracture of the radius. Ultimately however, casting is more labor intensive and not always an available option. Some recent recent reports may also lead to us to use removable velcro splints for certain non displaced fractures. This is an area of ongoing study.
What do I need for supplies?
- Cotton stockinette
- Cotton bandage; i.e. Webril
- Orthoglass or plaster cut to predetermined length
- Pick a size large enough (enough to cover ~1/2 the circumference of the extremity)
- Traditionally, plaster of Paris has been used but now there are many additional options including fiberglass, which is what we used in many EDs
- Access to a sink or water to wet orthoglass
- Ace bandage(s)
What are the basic steps that I need to know when applying a splint?
- Stretch stockinette over the affected extremity. Make sure that it’s long enough to extend beyond the proximal and distal edges of the area you’re splinting.
- Wrap Webril around the extremity making sure to avoid wrinkles because this can lead to pressure sores. Extend the padding 2 to 3 cm beyond the area to be splinted.
- Cut orthoglass to correct length depending on type of splint you are applying.
- Place orthoglass under room-temperature water and use a towel to remove excess water
- Mold orthoglass on to the extremity and fold back the ends to make a smooth edge. Then, fold stockinette over the edge.
- Wrap an elastic bandage around the site. Ensure the wrap is not too tight to cause constriction.
- Make sure to keep the limb in the desired position until the orthoglass hardens.
See this video, from the AAP’s PediaLink site for more details
Which type of splint do I choose?
Depending on the location of type of injury, there are multiple variations of upper extremity splints that we utilize.
Uses: Wrist and distal forearm fractures; ie, distal radial and ulnar fractures.
Construction: Extends from the dorsal aspect of the knuckles around the elbow, along the forearm to the palmar crease.
Position of extremity: The forearm is in a neutral position and the wrist is slightly extended.
Long Arm Posterior
Uses: Injuries to the elbow, proximal forearm fractures.
Construction: Extends from wrist along posterior arm to the proximal humerus.
Position of extremity: Elbow is flexed at 90 degrees and forearm/wrist are in a neutral position. Can also be at 45 degrees if this is the only position the patient can tolerate.
Uses: Buckle fracture of the distal radius, carpal bone fractures (excluding the scaphoid), 2nd-5th metacarpal fractures
Construction: Extends from the metacarpal heads along the volar aspect of the forearm to just near to radial head
Position of extremity: The forearm is in a neutral position and wrist is in ~20 degrees of extension.
Uses: Distal scaphoid fractures, fractures of the 1st metacarpal, phalangeal fractures, MCP joint sprains.
Construction: Extends from the thumb to the proximal forearm.
Position of extremity: The forearm is in a neutral position with the wrist ~20 degrees extension and the thumb slightly flexed.
Uses: 4th and 5th metacarpal fractures with none to minimal angulations and no rotational deformity.
Construction: Extends from proximal/mid forearm to just beyond the DIP joint.
Position of extremity: The wrist is slightly extended, the metacarpophalangeal (MCP) joints are in 70 to 90 degrees of flexion, and the PIP and DIP joints in 5 to 10 degrees of flexion.
Uses: 2nd and 3rd metacarpal fractures.
Construction: Extends from proximal/mid forearm to just beyond the distal DIP joint of the 2ndand 3rd digits.
Position of the extremity: The forearm is in a neutral position, wrist is slightly extended, MCP is in ~50 degrees of flexion with PIP and DIP joints in 5 to 10 degrees of flexion.
What are the possible complications of applying a splint?
Pressure sores leading to possible infection could result from splints that are ill fitted. If the splint is applied too tightly neurovascular compromise may occur. Always be sure to check neurovascular status on your initial evaluation as well as after splint application.
What anticipatory guidance should I provide the family?
The patient should seek medical attention if they experience any numbness, tingling, or issues with pain control after leaving the ED. We typically advise follow-up with orthopedics ~7days after injury for re-evaluation and likely casting.
- Klig J. Splinting procedures. In: Textbook of Pediatric Emergency Procedures, Henretig F, King C, Joffe M. (Eds), Lippincott, Williams & Wilkins, Baltimore 2008. p.919.
- Boyd AS, Benjamin HJ, Asplund C. Principles of casting and splinting. American Family Physician 2009; 79:16
- Boyd AS, Benjamin HJ, Asplund C. Splints and casts: indications and methods. American Family Physician 2009; 80:419
- Howes DS, Kaufmann JJ. Plaster splints: Techniques and indications. American Family Physician 1984: 30:215
- Kronful R. Splinting of musculoskeletal injuries.https://www.uptodate.com/contents/splinting-of-musculoskeletal-injuries?source=search_result&search=splinting&selectedTitle=1~150