1. ED 103: splinting basics Thao M Nguyen, MD Daniel A Hirsh, MD Pediatric Emergency Medicine Emory University Children’s Healthcare of Atlanta

2. 2 Objectives  Indications & Contraindications  Basic Principles  Common Mistakes  Prepare patient/parent  Step-by-step instructions  Complications  Discharge Instructions

3. 3 Indications  Temporary immobilization  Protection  Pain control

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

5. 5 Basic Principles  Temporary  Non-circumferential  Non-weight bearing  Protect the skin Pad bony prominences Place a dry splint

6. 6 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

7. 7 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 shouldn’t tingle or turn deep purple

8. 8 Step 1: Choose your splints

9. 9 Choosing the splint types: upper extremities  Volar Distal radius/ ulna & wrist fx  Sugar Tong Distal radius/ ulna & wrist fx  Long Arm Elbow & forearm injuries - Fleisher, 2006 -

10. 10 Choosing the splint types: upper extremities  Ulnar Gutter Boxer’s fx and uncomplicated 4 th & 5 th phalangeal fx  Radial Gutter 2 nd & 3 rd MCP or phalangeal fx - Fleisher, 2006 -

11. 11 Choosing the splint types: upper extremities  Thumb Spica Nonrotated, nonangulated, nonarticular fx of the thumb MCP or phalanx; gamekeeper’s thumb; scaphoid (navicular fx)  Buddy Tape - Fleisher, 2006 -

12. 12 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 -

13. 13 Step 2: Gather all of your supplies

14. 14

15. 15 Splinting Material

16. 16 Stockinette

17. 17 “Cotton Wadding” “Cast Padding”

18. 18 Ace wrap

19. 19 Shears

20. 20 Step 3: Protect the skin

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

22. 22 Cut out any areas that bunch up that could damage the skin

23. 23 Create thumb hole

24. 24 Protect bony prominences

25. 25 Cut splint material to proper size

26. 26 Protect the skin by creating ~1.5 cm border of cotton by cutting the fiberglass

27. 27 Step 4: Activate the Fiberglass

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

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

30. 30 Cold water

31. 31 Keep padding as dry as possible

32. 32 Protect the skin. If cotton padding is wet, dry it.

33. 33 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.

34. 34 Step 5: Apply the Splint

35. 35 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.

36. 36

37. 37 Allow time for the fiberglass to cure

38. 38 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

39. 39 Splint Complications

40. 40 Discharge Instructions  Protect the skin. Keep splint dry  If extremities become tingly or blue, re-wrap the bandage  Don’t allow weight bearing on the splint  If splint hurts, or there is increasing pain, TAKE THE SPLINT OFF! Seek medical attention

41. 41 Case 1 12 yo female s/p bike accident, fell and landed on wrists

42. 42 Case 2 3 yo male fell while running and landed on leg

43. 43 Case 2

44. 44 Case 3 16 yo female with left wrist injury ~ 6 wks ago. Extremity was splinted w/o reduction; unable to F/U with orthopedics

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