Lower Extremity Splinting

Jeff Harris, MD
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Subject: Lower Extremity Splinting

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Introduction

The five primary uses of splints are to immobilize fractures, dislocations, subluxations, sprains/strains, and painful joints. Secondarily, splints may be temporarily used to stabilize soft tissue injuries such as deep lacerations that cross joints. Splinting may be used as a definitive treatment in certain clinical situations such as de Quervain tenosynovitis. 
Splints should be placed as soon as possible after the injury occurs. The immobilization of an extremity through splinting decreases pain and prevents further injury such as vascular injury, neurological compromise, and soft tissue injury. Ideally the splint should be left in place until the extremity has been fully and properly evaluated for more aggressive management such as surgery and/or casting, or until the fracture has healed. Splints remain the superior treatment in acute injury settings because they allow for swelling, which decreases the possibility of neurovascular compromise. 
The knee splint is used to stabilize knee injuries and proximal tibia or fibula fractures. It is applied with the knee in full extension. The splint is placed from the posterior buttock down the posterior leg, knee, and calf to 3 inches above the level of the lateral malleolus. The posterior leg splint is used for distal leg, ankle, tarsal, and metatarsal fractures as well as ankle dislocations and severe sprains. It starts from the metatarsal heads on the plantar surface of the foot and extends up the back of the leg to the level of the fibular neck. These splints can be used along with a stirrup splint for unstable ankle fractures. The stirrup splint prevents eversion and inversion of the ankle joint. It is applied from below the medial side of knee and wrapped around the undersurface of the heel, then back up to the lateral side of the same knee. Stirrup splints, when used with a posterior leg splint, are better referred to as a Sarmiento splint. Buddy taping is used for phalangeal fractures of the toes. A small wadding of cotton is placed between the toes to prevent maceration. The fractured toe is secured to the adjacent toe with tape. 
There are several types of splinting material available. Plaster splints consist of various width strips of a crinoline-type material impregnated with plaster of Paris, which crystallizes (hardens) after water is added. They are easier to mold and less expensive than other materials. However, they are more difficult to apply, are messy, are heavy, take longer to set, and are not water resistant (they get soggy when wet). Prefabricated splint rolls include 2-, 3-, 4-, and 6-inch rolls consisting of layers of fiberglass between polypropylene padding. These splints set more quickly, are lighter and stronger, and are water resistant. However, they are more expensive and difficult to mold. Air splints are preformed inflatable splints that are comfortable and indicated for ankle sprains but are not indicated for fractures or dislocations, and they are not discussed here. 

Equipment

  • Stockinet

  • Cast padding

  • Splinting material

  • Elastic bandage (e.g., Ace bandage)

  • Adhesive tape

  • Heavy scissors

  • Room-temperature water

  • Bucket

  • Gloves

  • Splinting material

Indications

  • To improve pain, decrease blood loss, reduce the risk for fat emboli, and minimize the potential for further neurovascular injury associated with fractures

  • To improve pain associated with sprains

  • To immobilize tendon lacerations

  • To immobilize extremities associated with deep lacerations across joints

  • To immobilize painful joints associated with inflammatory disorders

Contraindications

  • Fractures that meet indication for emergent orthopedic surgical evaluation

  • Open fractures

  • Angulated fractures

  • Displaced fractures

  • Irreducible dislocations

  • Neurovascular compromise

The Procedure

Knee Splint

Step 1
Prepare the patient by inspecting the skin for lacerations. Repair any injuries and clean any wounds before splinting. Prepare the stockinet by cutting it to fit the size of the leg being splinted. Allow 3 to 4 inches of extra material above and below the level of each end of the splint, which allows the ends of the stockinet to be folded back. Apply stockinet to limb. 
  • PEARL: Having the patient lie in the prone position on the examination table will make placing the splint an easier task.

Step 2
Roll the cast padding onto the leg, starting at the most distal end of the extremity and work proximally. The knee should be placed in full extension prior to wrapping to prevent kinks in the cast padding. Each layer should overlap the previous layer by about 50%. 
  • PEARL: Make sure to add extra cast padding at the most distal and proximal ends to avoid irritation to the ankle and buttock.

  • PEARL: Use extra padding at sites of bony prominences and ends of splint to decrease the chance of pressure sores.

  • PEARL: Cast padding should be rolled with the bulk of the material on top of the sheet adjacent to the skin. The rolling should be effortless.

Step 3
Prepare 10 to 15 sheets of plaster (which is enough for most lower extremity splints). Next, estimate the length needed by laying the splint sheets over the injured extremity. You may need to tear a small amount off one end of the splint sheets if the original length is too long. 
  • PEARL: Alternatively, when using fiberglass material, simply measure the extremity to be splinted. Unroll a length of fiberglass material, and accordion fold the material to the correct length. Then use scissors to cut the accordion fold away from the remaining roll.

Step 4
Immerse the splint material in room-temperature water. Squeeze out all the water and smooth the splint taking out all the wrinkles. Place the splint on the posterior side of the leg while immobilizing the patient’s knee joint. It is applied from the posterior buttock down the posterior leg, knee, and calf to 3 inches above the level of the lateral malleoli. 
  • PITFALL: Never use hot water, which can cause an excessive thermochemical reaction and extremely rapid setting of the cast material. The cast material should never be wrung out.

Step 5
Roll the ends of the stockinet back over the splint, allowing a thick layer of padding at both ends to avoid irritations and lacerations from the splint material. Smooth and mold the splint as it sets. 
  • PITFALL: Always use the palms of your hands to smooth and mold the splint. Excessive use of the fingers can cause indentions in the splint, which can lead to pressure sores.

Step 6
Secure the splint material with another single layer of cast padding. Mold the splint with the palm of your hand while keeping the extremity in full extension. 
Step 7
Hold the newly formed splint in full extension until it hardens (approximately 3 to 5 minutes) and wrap the outer layer with an elastic bandage. 
  • PITFALL: Wrapping the elastic bandage too tightly could lead to vascular compromise and not allow for swelling.

  • PEARL: Always allow for ankle and hip range of motion to prevent joint stiffness.

Posterior Leg Splint

Step 1
Begin by measuring, cutting, and placing the stockinet as discussed for the knee splint except this stockinet should be measured to incorporate the entire foot up the knee. 
  • PEARL: Having the patient lie in the prone position on the examination table will make placing the splint an easier task.

Step 2
Next, place the cast padding. Start by wrapping the padding distally around the toes and work your way proximal until the knee is reached. The ankle should be placed in 90 degrees of dorsiflexion. 
  • PITFALL: Failing to place the ankle in 90 degrees of dorsiflexion will make it more difficult for your patient to regain range of motion once the splint is removed.

  • PEARL: When immobilizing Achilles tendon injuries, the ankle should always be splinted in plantar flexion. Failing to splint an Achilles rupture in plantar flexion could allow tracking of the proximal portion of the tendon high into the leg, making surgical repair more difficult.

Step 3
Measure the approximate length of plaster sheets. These should be long enough to be placed from metatarsal heads on the plantar surface of the foot and extend up the back of leg to the level of the fibular neck. 
Step 4
Submerge the plaster sheets in room-temperature water. Squeeze all the water out of the plaster sheets and smooth out all the wrinkles. 
  • PITFALL: Never use hot water, which can cause an excess thermochemical reaction and extremely rapid setting of the material. The splint material should never be wrung out.

  • PEARL: Alternatively, when using fiberglass material, simply measure the extremity to be splinted. Unroll a length of fiberglass material, and accordion fold the material to the correct length. Then use scissors to cut the accordion fold away from the remaining roll.

Step 5
Mold the plaster sheets on the plantar surface of foot, posterior ankle, and leg. 
  • PITFALL: Always use the palms of your hands to smooth and mold the splint. Excessive use of the fingers can cause indentions in the splint, which can lead to pressure sores.

Step 6
Roll both the distal and proximal ends of the stockinet back over the splint, allowing a thick layer of padding at both ends to avoid irritations and lacerations from the splint material. Secure the splint by wrapping a layer of cast padding around the entire outside of the splint. Wrapping should start at distal end of extremity and continue proximally to cover the entire splint. 
Step 7
The splint should be molded with the ankle in approximate 90 degrees of dorsiflexion. Once the splint hardens, place an elastic bandage over the entire splint. 
  • PEARL: For unstable ankle fractures, this splint should be used in combination with a stirrup splint.

Stirrup Splint

Step 1
Because this splint is most commonly used in combination with a posterior leg splint (Sarmiento splint), you should not have to re-apply the stockinet and cast padding before placing this splint. Those steps should have taken place prior to placing the posterior leg splint. 
  • PEARL: Having the patient lie in the prone position on the examination table will make placing the splint an easier task.

Step 2
Measure the length of the plaster sheets against the patient’s leg and tear or cut to length. The strips should be long enough to involve the leg from below the medial side of knee, wrap around the undersurface of the heel, and back up to the lateral side of the same knee. 
  • PEARL: This part of the splint is to prevent inversion and eversion of the ankle.

  • PEARL: In some patients, the long splint material (5 inches × 30 inches) may not be long enough to reach from one side of the knee to the other. In this situation, you can measure and tear the material to cover from the medial side of knee to the lateral heel. Then measure and tear another piece to cover from the lateral side of the knee to the medial heel. When placing the splint, the two pieces should overlap at the undersurface of the heel.

Step 3
Submerge the plaster in room-temperature water, then squeeze out all the water and smooth out the wrinkles. 
  • PEARL: Alternatively, when using fiberglass material, simply measure the extremity to be splinted. Unroll a length of fiberglass material, and accordion fold the material to the correct length. Then use scissors to cut the accordion fold away from the remaining roll.

Step 4
Mold the splint around the ankle to prevent inversion or eversion. 
  • PITFALL: Always use the palms of your hands to smooth and mold the splint. Excessive use of the fingers can cause indentions in the splint, which can lead to pressure sores.

Step 5
Roll both the distal and proximal ends of the stockinet back over the splint, allowing a thick layer of padding at both ends to avoid irritations and lacerations from the splint material. Wrap the outer layer of the splints with cast padding. Start by wrapping the padding distally around the foot and ankle and then work proximally. Starting distally around the foot and ankle will hold the splint in place while you prepare to finish the splint. 
Step 6
Once the splint hardens, finish by wrapping an elastic bandage over the entire splint. 

Buddy Taping

Step 1
Start by folding a 3- × 3-inch cotton pad in half. Place the cotton pad or some other form of wadding between the affected and adjacent toe to prevent maceration. Tear a piece of tape, and secure the injured toe to the adjacent toe. 

Complications

  • Pressure sores result from insufficient padding over bony prominences or indentions in plaster from improper use of fingers to mold the splint or improper support of splint while hardening.

  • Compartment syndrome occurs less commonly with splints than casts. Presenting signs of compartment syndrome include pain, pallor, paresthesias, paralysis, and lack of pulse. Avoid this by wrapping cotton padding with minimal pressure and minimize swelling with ice and elevation. Immediate splint removal and orthopedic consultation is required if compartment syndrome is suspected.

  • Infection may occur if the patient places sharp instruments down the splint for scratching (e.g., a coat hanger). It is more common with open wounds present prior to splinting. The provider may prevent this complication by cleaning wounds well before splinting.

  • Heat injury may result from plaster-generated heat during crystallizing. Reduce the risk of thermal injury by applying an appropriate amount of cotton padding and using room-temperature water.

  • Joint stiffness may occur. Splinting the extremities in their position of function will reduce joint stiffness and make it easier to get range of motion back once the splint is removed. Avoid prolonged immobilization if possible.

Pediatric Considerations

Children who present with swelling, immobility, pain with movement or palpation, anatomic deformity, discoloration, or crepitus should have radiographic studies. Immediate orthopedic consultation is needed for severe musculoskeletal injuries such as open fractures, evidence of neurovascular compromise, fractures and dislocations that cannot be easily reduced in the office or emergency department, or fractures that are displaced or too angulated to be splinted. 
Patients with sprains need special attention because a sprain may represent a Salter-Harris type 1 injury that does not have any radiographic evidence of a fracture. Any patient who has tenderness over the physis (growth plate) should be presumed to have a Salter-Harris type 1 fracture and appropriate splinting should take place to immobilize the extremity. Be aware of tenderness to palpation at the injured site during the follow-up visit in 7 to 10 days. This could represent a nondisplaced Salter-Harris type 1 fracture, and additional follow-up radiographs should be ordered to confirm clinical suspicion. Rapid resolution (2 to 3 days) of tenderness after splinting implies the absence of a Salter-Harris type 1 fracture. 

Postprocedure Instructions

Patients should be instructed to elevate and ice the extremity to minimize swelling. Ice can be applied using cold packs such as frozen bags of vegetables or ice bags for 15 to 20 minutes at a time for the first 48 hours. They should also be given instructions to not get the splint wet and not to remove it unless the provider has made it removable. Splints should be placed in a plastic bag while bathing to keep dry. Make sure the patient understands symptoms of neurovascular compromise. Patients should know to return if the splint gets wet or starts to come apart. They should also be instructed not to stick any objects (especially sharp objects such as hangers) down the splint to scratch. These recommendations should be given in writing as well as verbally. 

Coding Information and Supply Sources

Suppliers

Plaster of Paris splinting material can be obtained from these suppliers: 
Fiberglass splinting material can be obtained from this supplier: 

Bibliography

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Erick IM. Splinting. In: Yamamoto LG, Inada AS, Okamoto JK, eds. Case-Based Pediatrics for Medical Students and Residents . Department of Pediatrics University of Hawaii John A. Burns School of Medicine;  2004. http://www.hawaii.edu/medicine/pediatrics/pedtext/s19c02.html.
Marshall PD, Dibble AK, Walters TH, et al. When should a synthetic casting material be used in preference to plaster-of-Paris? a cost analysis and guidance for casting departments. Injury .  1992;23:542–544. [View Abstract]
Rowley DI, Pratt D, Powell ES, et al. The comparative properties of plaster of Paris and plaster of Paris substitutes. Arch Orthel Orthop Trauma Surg.  1985;103:402–407. [View Abstract]
Principles of fractures and dislocations. In: Rockwood Jr CA, Green DP, Bucholz RW, eds. Rockwood and Green Fractures in Adults , 3rd ed. Philadelphia: Lippincott;  1991:25–27.
Smith G, Hart R, Tsai T. Fiberglass cast application. Am J Emer Med .  2005;23:347–350. [View Abstract]
Lucas GL. General orthopaedics. In: Green WB, ed. Essentials of Musculoskeletal Care , 2nd ed. (IL): American Academy of Orthopaedic Surgeons,  2001:81–82.
2008 MAG Mutual Healthcare Solutions, Inc.’s Physicians’ Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc. 2007.
 
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