Patients commonly present to emergency departments, primary care offices, or specialty clinics with musculoskeletal injuries. The initial management of an acute traumatic limb injury involves a thorough history and physical evaluation of the injury, which includes a motor, sensory, and neurovascular examination. Injuries that result in instability require immobilization, decreasing the likelihood of further damage, protecting soft tissues, alleviating pain, and accelerating healing. Instability may result from direct injury to the bones (fracture), joints (dislocation), or the soft tissues such as the muscles (strain) or ligaments (sprain). Following the diagnosis of an unstable injury, a splint may be the best treatment option and is loosely defined as an external device used to immobilize an injury or joint and is most often made out of plaster. A splint must be differentiated from a cast, to determine the best form of immobilization based on the clinical scenario. Contrary to a splint, a cast is a circumferential application of plaster that rigidly immobilizes a particular joint or fracture. Because of their circumferential restrictive nature, casts are not placed in the acute post-injury setting as they do not accommodate for soft tissue swelling.
Different forms of splints may be fashioned depending on injury location and position of immobilization needed. The goal of splinting is to correct and restore anatomic length, rotation, and angulation of a patient-specific injury. Splints are treatments utilized by a variety of medical personnel as either a temporizing or definitive management strategy for stable fractures. Proper splint placement is essential since malpositioning can cause undue pain, malreduction, and skin breakdown. Improper splinting not only necessitates replacement, but splint-related soft tissue complications are the second most common iatrogenic cause for referral to plastic surgery. Poor splinting techniques are common, with one study demonstrating inappropriate splinting on 93% of patients. As such, a thorough understanding of the indications, contraindications, and approach to proper splint placement is essential for practitioners that treat patients with acute musculoskeletal injuries.
Fashioning a splint takes patient-specific anatomy into account. The splint should be fashioned such that it restores anatomic resting joint position to minimize adverse outcomes. Plaster or fiberglass splints are the mainstays of acute immobilization. Plaster is the preferred malleable material to maintain a position-specific reduction, but it is limited by drying time, user experience, and provider-placed mold. Fiberglass splints are lighter, easier to apply, and more porous, but are more expensive and provide a less-reliable mold. Pre-fabricated splints (such as foam splints or braces) may play a role in chronic injuries necessitating immobilization for structural support or pain control but are less commonly used in the acute fracture setting.
Upper extremity splints crossing the wrist should maintain neutral wrist dorsiflexion, and vascular status should be assessed before and after application to reduce the risk of subsequent complications. In pediatric patients with supracondylar elbow fractures, the arm should never be splinted with the elbow flexed more than 90 degrees, as this increases the risk of Volkman's ischemic contracture. Lower extremity splints crossing the ankle joint should place the ankle in a resting neutral position without excessive ankle plantarflexion to prevent resultant Achilles flexion contractures. Excess pressure on the soft tissues may decrease the blood flow to the skin surface; this is of particular importance in areas with bony prominences, such as the elbow, knee, and calcaneus, as excess pressure may cause skin irritation and necrosis. Additional layers of protection during the splinting process is of great importance in these regions.
Conversely, excessive splint laxity may permit excessive movement of the injury, and, in cases of fractures, this may result in loss of bony reduction. If a splint is a definitive therapy, there must be a stable injury pattern. Fractures that are difficult to reduce, excessively shortened, or comminuted are not candidates for definitive splinting, as they usually will need operative intervention by an orthopedic surgeon. However, unstable injuries may still benefit from temporary splinting if the patient is not an immediate candidate for surgery due to concurrent medical issues or if there is an anticipated delay before definitive operative fixation. In these cases, temporary splinting is necessary to avoid further injuries, immobilize the fracture, and promote healing.
Splints are placed to immobilize musculoskeletal injuries, support healing, and to prevent further damage. The indications for splinting are broad, but commonly include:
No specific contraindications to splinting exist. However, certain injuries and patient-specific comorbidities require special attention:
Obtain and organize all equipment before splint application. The necessary equipment for a plaster or fiberglass splint includes:
Splints may be applied by physicians, physician assistants, first-responders, medical assistants, and technicians with the proper training. Although a sole individual may apply a splint, assistance is commonly needed for ease of application. A second provider can gather materials, aid in reduction, and secure the injured limb in position so that the primary provider can adequately place and mold the splint.
All materials should be obtained before splint application to avoid the premature setup of the plaster/fiberglass. A careful history and physical exam, including a motor, sensory, and neurovascular exams, should be performed before treatment. Open wounds or soft tissue injuries should be addressed during the preparation phase. Depending on the clinical circumstances., wounds may require antibiotics, wound irrigation, debridement, or tissue closure. The patient’s clothing should be covered with a sheet or pad to prevent plaster or fiberglass from being deposited onto them. A bucket of water must be obtained to activate the plaster or fiberglass. The splint materials should be measured to fit the desired area, precut, and laid out in the order of use; specifically, a stockinette should be cut to a size that is 8-10cm longer than necessary to cover the splinted area. The plaster or fiberglass should also be measured and cut to an appropriate length, spanning the entire injured area and then stacked 8-10 sheets thick to ensure adequate strength. Additional layers may be necessary for larger joints or larger body habitus, and similarly, fewer may be required in the setting of pediatric cases. Analgesia may be required either by oral or intravenous (IV) routes. Conscious sedation may be needed for pediatric patients.
General steps may be applied when placing a splint
Common upper extremity splints include:
Common lower extremity splints include:
These specific splinting approaches are well described elsewhere.
While splints are commonly used, they are often applied improperly or inadequately. Patients should be given a list of signs and symptoms that necessitate a prompt return to a medical professional. Complications include:
Splints may be used to effectively immobilize an injury, including a sprain, fracture, or soft tissue injury. In specific scenarios, splints may be used as definitive management to treat these injuries. Educating patients regarding splint care and return precautions aids in a successful outcome.
A splint must be differentiated from a cast, to determine the best form of immobilization based on the clinical scenario. A splint is a non-circumferential application of plaster or fiberglass that is particularly useful in the acute post-injury setting. A splint's supportive and forgiving structure allows physiologic swelling common to the acute inflammatory phase. In contrast, a cast is a circumferential application of plaster that rigidly immobilizes a particular joint or fracture. Because of the circumferential nature, casts are commonly not placed in the acute post-injury setting.
Splint application is not a completely benign treatment, and improper placement may result in adverse outcomes. One study found that 40% of patients splinted in the emergency department developed soft tissue complications, including skin ulceration in 6% of patients. Proper splint placement avoids unnecessary pain, complications, and excess healthcare costs. Careful monitoring for subsequent compartment syndrome, neurovascular compromise, skin breakdown, or necrosis should be maintained in the early post-injury period. Patients who complain of numbness or tingling in the affected limb, pale skin, numbness or tingling, or increased pain and swelling should be evaluated immediately for potential complications. Patients should be educated on proper splint care, elevating the injured extremity, keeping it clean and dry. Additionally, the patient should be counseled on return precautions, such as an acute increase in pain or any change in motor or sensory functions.
Splints may be applied by medical personnel with a wide range of clinical backgrounds. Regardless of experience, basic knowledge about proper splint application and complications allows teams to work together to care for patients effectively. Following fracture splinting, follow up care should be coordinated for the patient to ensure improving clinical status. Often this coordination occurs between emergency physicians or first responders and primary care physicians or pediatricians for injuries that do not require specialty level care or operative fixation. This is particularly relevant in the case of pediatric forearm fractures, where most patients receive follow-up care with primary care physicians and not orthopedic specialists. In the setting of multi-trauma, fractures with significant displacement, rotation or malalignment, peri-articular fractures, and open injuries, care should be coordinated with an orthopedic surgeon following the initial provider's evaluation. Additionally, in these patients with an increased risk of adverse events, post-discharge follow-up phone calls should be arranged to ensure the appropriate continuity of care.
Splints may be applied by appropriately trained physicians, physician assistants, nurses, technicians. A thorough history and physical exam must be obtained before any intervention. Medical professionals may serve as the primary treating clinician or splinting assistant. Regardless of the role assumed, knowledge about the goals of immobilization and proper splinting techniques will improve patient care. Coordination with an orthopedic specialist is necessary for any unstable injuries.
Non-orthopedic medical professionals frequently treat patients with acute injuries that require splinting. However, few of these professionals are comfortable splinting injuries, and many have not received dedicated education on proper technique. Incorporating an inter-residency and interprofessional approach between orthopedic surgeons, emergency medicine physicians, family practitioners, and advanced practitioners can significantly improve these skills.
Following the splint application, the patient should be instructed regarding proper splint care, including keeping the splint clean and dry, elevating the injured extremity to minimize swelling and
Strict return precautions include getting the splint wet, change in motor function, sensation, or neurovascular status. Non-operative patients managed in a splint require follow-up care in 1 to 2 weeks after the initial splint placement. Further evaluation may include repeat X-rays, splint change, or conversion to a cast.
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