Upper Extremity Short Arm Splinting

Jeff Harris, MD
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Subject: Upper Extremity Short Arm Splinting

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Introduction

Splinting plays a major role in the management of musculoskeletal injuries. Splints are used to temporarily immobilize fractures, subluxations/dislocations, sprains, or painful joints associated with inflammatory disorders. They also may be utilized to immobilize soft tissue injuries, such as deep lacerations that cross joints, until further evaluation and/or casting can be accomplished. Splinting may be used as a definitive treatment in certain clinical situations such as de Quervain tenosynovitis. 
Immobilization of an extremity through splinting decreases pain and prevents further injuries, including vascular injury, neurological compromise, and soft tissue injury. A splint should be placed as soon as possible after the injury occurs. It should ideally be left in place until the injury has been fully evaluated, other therapy initiated, or until the injury is adequately healed. Splints allow for swelling, which decreases the possibility of neurovascular compromise. This makes them superior to casting in acute injury settings. 
The volar splint is used to stabilize distal forearm and wrist fractures. It is applied from the volar palmar crease to a point that covers two thirds of the forearm. The ulnar gutter splint is used for phalange and metacarpal fractures and is most commonly used for boxer fractures. It starts at the distal interphalangeal (DIP) joint and covers the proximal two thirds of the forearm. The function of the ulnar gutter splint is to immobilize the ring and little finger. The thumb spica splint is used for scaphoid fractures, thumb phalanx fractures and/or dislocations, gamekeeper’s thumb (skier’s thumb), and de Quervain tenosynovitis. It starts at the DIP joint of the thumb (incorporating the thumb) and covers the proximal two thirds of radial forearm. 
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 or gypsum, which crystallize (harden) after water is added. Their advantage is that 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; they are indicated for ankle sprains but not for fractures or dislocations and 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 (e.g., de Quervain tenosynovitis)

Contraindications

  • Fractures that meet indications for emergent orthopedic surgical evaluation

  • Open fractures

  • Angulated fractures

  • Displaced fractures

  • Irreducible dislocations

  • Neurovascular compromise

The Procedure

Volar Splint

Step 1
Prepare the patient by inspecting the skin for lacerations. Repair any injuries and clean any wounds before splinting. Prepare a stockinette by cutting it to fit the size of the limb 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 the stockinet to limb. 
Step 2
Make a small cut over the thumb area of the stockinet to allow the thumb to protrude through the stockinet. 
  • PITFALL: Do not cut the patient’s thumb while cutting the stockinet.

Step 3
Roll the cast padding onto the arm, starting at the most distal end of the extremity and work proximally. The cast padding should cover the extremity above and below the fracture/injury site. 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 fingers and elbow.

Step 4
Make sure to allow the thumb to come through the cast padding as shown. This will reduce the chance of irritation and sores to the skin around the thumb from the plaster that will be placed. 
  • 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 5
Prepare 8 to 10 sheets of plaster for most upper extremities 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. 
Step 6
Tear out an area around the thumb to allow for a better fit. 
Step 7
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 a notch for the thumb as described previously. 
Step 8
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 radial side of the forearm while immobilizing the patient’s joints above and below the fracture/injury site. It is applied from volar palmar crease to a point that covers two thirds of the forearm. 
  • PITFALL: Never use hot water, which can cause an excess thermochemical reaction and extremely rapid setting of the cast material. The cast material should never be wrung out.

  • 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 9
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. 
Step 10
Secure the splint material with another single layer of cast padding. Mold the splint with the palm of your hand and place extremity in the position of function. 
Step 10
Step 10
Step 11
Hold the newly formed splint in position 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 will not allow for swelling.

  • PEARL: Always allow for finger and elbow range of motion.

Step 11
Step 11

Ulnar Gutter Splint

Step 1
Begin by measuring, cutting, and placing the stockinet as discussed for the volar splint. Cut the stockinet between the ring and little finger to allow wrapping of these fingers. 
  • PEARL: It may helpful to cut a slit in the stockinet between the ring and middle finger so that the splint only incorporates the little and ring finger, leaving the other three fingers free for motion.

Step 2
Next, place the cast padding by wrapping the padding around the ring and little finger, leaving the middle and pointer finger exposed. Work proximally toward the palm of hand, around the thumb, and up two thirds of the proximal forearm. 
Step 3
Measure the approximate length of plaster sheets. These should be long enough to involve the distal interphalangeal (DIP) joint and extend over two thirds of the proximal forearm. 
Step 4
Tear a slit at one end of the plaster sheets so that it will be easier to form a mold around the ring and little finger, then 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: Creating a slit in the plaster before wetting will make it easier to form a mold around the ring and little finger.

Step 5
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 a slit at one end as described previously. 
Step 6
Mold the plaster sheets on the ulnar side of fingers, wrist, and forearm with the torn end distal. Immobilize the ring and little finger by wrapping the torn end of plaster around them. 
  • 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 7
Secure the splint by wrapping a layer of cast padding around the entire outside of the splint. Wrapping should start at distal end of the extremity and continue proximally to cover the entire splint. 
Step 8
Roll both the distal and proximal ends of the stockinet back over the splint, allowing a thick layer of padding at both ends, which avoids irritations and lacerations from the splint material. 
Step 9
The splint should be molded with the metacarpophalangeal joint in approximate 70 degrees of flexion, the proximal interphalangeal (PIP) joint in 30 degrees of flexion, and the DIP joint in no more than 10 degrees of flexion. Once the splint hardens, place an elastic bandage over the entire splint. 

Thumb Spica Splint

Step 1
Begin by measuring, cutting, and placing the stockinet as discussed for the volar splint. Place the cast padding as discussed for volar splint, but with this splint, wrap the thumb as well. 
Step 2
Measure the length of plaster sheets against the patient’s arm and tear or cut to length. The strips should be long enough to involve the entire thumb and extend two thirds down the proximal forearm. 
Step 3
Make a 1- to 3–inch-long tear in one end of the plaster sheets so that the thumb can be wrapped and immobilized easier. Submerge the plaster in room-temperature water, then squeeze out all the water and smooth out the wrinkles. 
Step 4
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 a slit at one end as described previously. 
Step 5
Mold the splint on the radial side of the extremity to be splinted. 
  • 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
Form a mold around the thumb, allowing the thumb to remain in neutral or anatomical position. 
Step 7
Wrap outer layer of the splint with cast padding. Start by wrapping the padding around the thumb and work proximally. This will hold the splint in place while you prepare to finish the splint. 
Step 8
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. 
Step 9
Once splint hardens, finish by wrapping an elastic bandage over the entire splint. 

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 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 they may have 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 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 them 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 written as well as given verbally. 

Coding Information and Supply Sources

Suppliers

Plaster of Paris splinting material can be obtained from these suppliers: 
Specialized Medical Supplies Co. Ltd. Web site: http://www.specialized-medical/Plaster-of-Paris-slabs.htm  
Fiberglass splinting material can be obtained from this supplier: 

Bibliography

Bowker P, Powell ES. A clinical evaluation of plaster-of-Paris and eight synthetic fracture splinting materials. Injury .  1992;23:13–20. [View Abstract]
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.
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2008 MAG Mutual Healthcare Solutions, Inc.’s Physicians’ Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc. 2007.
 
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