ED 103: splinting basics Thao M Nguyen, MD

ED 103: splinting basics Thao M Nguyen, MD

ED 103: splinting basics Thao M Nguyen, MD Daniel A Hirsh, MD Pediatric Emergency Medicine Emory University Childrens Healthcare of Atlanta Objectives

Indications & Contraindications Basic Principles Common Mistakes Prepare patient/parent Step-by-step instructions Complications Discharge Instructions

2 Indications Temporary immobilization Protection Pain control 3

Contraindications Compartment syndrome Need for open reduction Skin at high risk for infection 4

Basic Principles Temporary Non-circumferential Non-weight bearing Protect the skin Pad bony prominences Place a dry splint

5 Common Mistakes Placement of a Circumferential splint Placement a Wet splint Placement of a Tight Splint Not allowing time for the fiberglass to adequately harden

6 Patient/Parent Expectations Placement should not hurt Most injuries feel significantly better with splinting alone Splint material will get warm when it hardens

Should be snug, not tight Fingers & toes shouldnt tingle or turn deep purple 7 Step 1: Choose your splints

8 Choosing the splint types: upper extremities Volar Distal radius/ ulna & wrist fx Sugar Tong

Distal radius/ ulna & wrist fx Long Arm Elbow & forearm injuries 9

- Fleisher, 2006 - Choosing the splint types: upper extremities Ulnar Gutter Boxers fx and uncomplicated 4th & 5th

phalangeal fx Radial Gutter 2nd & 3rd MCP or phalangeal fx 10 - Fleisher, 2006 -

Choosing the splint types: upper extremities Thumb Spica Nonrotated, nonangulated, nonarticular fx of the thumb MCP

or phalanx; gamekeepers thumb; scaphoid (navicular fx) Buddy Tape - Fleisher, 2006 11

Choosing the splint type: lower extremities Posterior leg Foot, ankle & distal fibula fx Ankle sprains Stirrup Foot, ankle & distal tibia/fibula fx

Cadillac Splint - Fleisher, 2006 12 Step 2: Gather all of your supplies 13

14 15 Splinting Material Stockinette

16 Cotton Wadding Cast Padding 17 Ace wrap

18 Shears 19 Step 3: Protect the skin 20

Apply stockinette to extremity Extend it past the proximal and distal ends of where the splint will end 21

Cut out any areas that bunch up that could damage the skin 22 Create thumb hole

23 Protect bony prominences 24

Cut splint material to proper size 25 Protect the skin by creating ~1.5 cm border

of cotton by cutting the fiberglass 26 Step 4: Activate the Fiberglass 27

Approximate initial hardening times Ambient Humidity: 15 min Cold Water: 5 min Hot Water: 2 min 28

Hot water will cause the fiberglass to harden very quickly 29 Cold water

30 Keep padding as dry as possible 31 Protect the skin. If cotton

padding is wet, dry it. 32 Some fiberglass material comes with a thick padded side and a thin side. Protect the skin. Always place the thick-side to

the skin-side. 33 Step 5: Apply the Splint 34

Wrap the splint in place not too loose or too tight. Protect the skin. Do not apply pressure with finger tips, use a curved palm. 35

36 Allow time for the fiberglass to cure 37 Step 6: Check splint placement

Make sure patient has normal sensation distal to splint Make sure there is normal capillary refill after splint placement Make sure the splint does not cause any pain 38

Splint Complications Complications Prevention Risk of ischemia Keep splint snug

Compartment Syndrome Possible neurovascular compromise Check distal neurovascular status after placement Skin breakdown

Keep splint dry Use minimal water necessary and dry thoroughly before placement Pain or Ineffective Immobilization 39

Use padding Avoid kinks Check splint after placement If either of these, replace the splint Discharge Instructions

Protect the skin. Keep splint dry If extremities become tingly or blue, re-wrap the bandage Dont allow weight bearing on the splint If splint hurts, or there is increasing pain, TAKE THE SPLINT OFF! Seek medical attention 40

Case 1 12 yo female s/ p bike accident, fell and landed on wrists

41 Case 2 3 yo male fell while running and landed on leg

42 Case 2 43 Case 3 16 yo female with

left wrist injury ~ 6 wks ago. Extremity was splinted w/o reduction; unable to F/U with orthopedics

44 Suggested Reading Fleisher, GR. Textbook of Pediatric Emergency Medicine, 5th ed, 2006 45

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