Common Splinting Techniques

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Common Splinting Techniques

• Jenniffer L. LaPointe, MD
• Lt Col, USAF, MC

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Why splint/cast?

• Acute musculoskeletal injuries common in primary
  care (especially in military!)
• Continuity
• Reduce orthopedic referral rate (experienced FP
  in orthopedics only 16-25 fracture referral rate
  excluding hip/face fractures)
• Studies concluding that most FP managed fractures
  heal well and most complications can be avoided
  with appropriate selection of which fractures to
  manage
• RVU density! Orthopedics pays

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RVU density

• Example Healthy 5 year old female comes in
  after FOOSH injury with nondisplaced torus fx of
  distal radius on x-ray, normal exam except for
  tenderness over distal radius
• On initial visit 99213 visit (0.67 RVUs) with
  CPT 29125, application of short arm splint (0.59
  RVUs) with total RVUs on initial visit 1.26
  RVUs
• THEN patient f/u done 3-4 days later after
  swelling has decreased and 99213 coded (0.67
  RVUs) and CPT 25500, closed treatment of radial
  shaft fracture without manipulation (2.51 RVUs)
  with total of 3.18 RVUs
• Follow up in 3 weeks with removal of cast, 99213
  (0.67 RVUs)
• Total of 5.11 RVUs for treatment and orthopedic
  referral avoided
• 2008 RVU values (increased 0.82 RVUs for CPT
  25500 vs 2006 values)

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Pre and Post Splint Checks

• F Function
• A Arterial Pulse
• C Capillary Refill
• T Temperature (Skin)
• S - Sensation

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Thumb Spica 3

• Indications for thumb spica
• Navicular / Scaphoid Fractures
• Thumb Dislocations/Proximal thumb fractures
• Ulnar Collateral Ligament Sprains
• Tendonitis
• Key Points
• 3 fingerbreadths from antecubital fossa
• Tip of thumb spiral
• 2 figure of 8 wraps with wrap

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When do I need an orthopedist?

• Indications for orthopedic referral
• Scaphoid Fractures any displacement or
  angulation, non-union or avascular necrosis
  develops after conservative treatment, or
  scapholunate dissociation (gt3mm distance)
• Proximal Thumb Fractures any intraarticular
  fracture, comminution, any fracture where
  adequate closed reduction cannot be maintained
• Ulnar Collateral Ligament Injuries avulsion
  fracture with more than 2 mm displacement,
  fractures with more than 20 articular surface
  involvement, complete rupture of UCL (tested at
  30 degrees flexion of MCP after radiographs are
  obtained)

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Volar Splint 3 or 4

• Indications
• Wrist Sprains
• Carpal Tunnel Syndrome/Night Splints
• Lacerations
• Simple/nondisplaced radius or ulna fractures
• Key Points
• palmar crease to 3 fingerbreadths from
  antecubital fossa
• 1 fold _at_ angle of palmar crease

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Teardrop Splint 4-5

• Indications
• 2nd 3rd Metacarpal Fractures
• Flexor Tendon Repairs or Extensor Tendon
• Crushing Injuries
• Lacerations
• Key Points
• Tip of 3rd finger to 3 fingerbreadths from
  antecubital fossa
• Cut 2 ½ hole for thumb tape edges
• Flex metacarpals 45 (70-90 if distal fracture)
  and wrist 20-30 extension

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Boxer Splint 4-5

• Indications
• 5th Metacarpal Fractures
• 4th Metacarpal Fractures
• Key Points
• Tip of 5th finger to 3 fingerbreadths from
  antecubital fossa
• Pad b/t 4th and 5th fingers
• Ulnar gutter
• Mold to position, MCP at 70-90 flexion to
  maintain positioning in distal fractures

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2 WEEKS LATER
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Reverse Sugar Tong 3- 4

• Indications
• Colles Fracture
• Forearm Fractures
• Key Points
• Measure from behind the elbow up both sides of
  the arm to the tip of the fingers
• Cut at mid-point leaving 1/2 and slide over the
  hand
• Overlap the ends at the elbow, wrap from the hand
  down

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Figure 8 Splint

• Indications
• Mid-shaft clavicular fractures (Proximal/distal
  clavicular fractures often treated with
  sling/swath /- operative treatment)
• Key Points
• Measure so position of attention attained
• Advantage of leaving elbow and hand free BUT
  requires assistance to put on
• Counsel patient bony deformity possible
• Orthopedic referral rarely indicated for
  mid-clavicular fractures

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Posterior Ankle 4 - 5

• Indications
• Distal Tib / Fib Fractures
• Ankle Sprains
• Achilles Tendon Tears
• Metatarsal Fractures
• Key Points
• 2 below popliteal to 2 beyond toes
• Fold 1 under toes
• Wrap from the toes up
• Figure 8 with tape to hold in position

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Reinforced Posterior Leg SplintButterfly

• Indications
• Severe Ankle Sprain
• Metatarsal Fractures
• Hair Line Fractures
• Distal Tibia / Fibula Fractures
• Non Displaced Ankle Fracture
• Key Points
• 2 below popliteal to 2 beyond the toes
• At base of heel snip padding
• Cut substrate 3-4 either side of mark
• Fold in Butterfly fashion
• Reinforced side away from patient

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When do I need an orthopedist?

• Referral decisions
• Avoid managing an orthopedic injury beyond your
  training/skill unless proper guidance is
  available
• Be able to identify patients with complicated
  fractures
• Need for surgical intervention to maintain
  reduction
• High risk of non-union
• Inability to maintain closed reduction
• Significant intraarticular involvement
• Strongly consider referring patients who are
  likely to be non-compliant

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Avoiding pitfalls

• Worst outcomes in fracture management
• Fractures requiring reduction
• Intraarticular fractures
• Scaphoid fractures
• Reference resources
• Up To Date
• Fracture Management For Primary Care, by Eiff,
  Hatch, and Calmbach
• Rockwood and Greens