Splinting in the Emergency Room

Hatem Alsrour

King Saud UniversityCollege of Nursing

Why Do We Splint?

• To stabilize the extremity

• To decrease pain

• Actually treat the injury

Complications of Splinting

• Abrasions

• Sores

• Neurovascular compromise (tight fitting splints)

• Contact dermatitis

• Pressure ulcers

• Thermal burns

How to prevent complications

• Apply splint by trained professional

• Apply splint correctly

• Monitor neurovascular status.

The 6 P’s of extremity assessment

Pain:

Palpate the entire extremity for increase pain

Pallor:

Note color and temperature and capillary refill

Pulses:

Palpate proximal and distal pulses

Paresthesia:

Assess for burning, tingling, numbness

Paralysis:

Assess motor function (both active and passive

Pressure:

Palpate for firmness of compartment

Equipment need for application

• Cotton bandage( soft roll, cotton roll) Pad entire area to be splinted

• Plaster slabs or pre padded fiberglass (Orthoglass), immobilize above and below injury

• Room temperature water (apply generously)• Elastic bandage• Adhesive tape or fastners

Types of Splints

•Yes,its broken and needs a splint!

•Why sure Doctor, not a• problem!

Volar Splint

• The Volar short arm splint is used for:

• Fractures of the wrist• Fractures of the

second to fifth metacarpals,

• Carpal tunnel syndrome

• Soft tissue injuries

Finger Splint

• Finger Splints are used for phalangeal fractures

• (A&B) commercial splints

• © is custom splint

Gutter Splint

• Two types: radial and ulnar

• Gutter splints are used for:

• Phalangeal fractures• Metacarpal fractures• Two types: radial and

ulnar

Figure Eight Splint

• Used to stabilize a clavicle fracture

• To be applied properly the patient must be erect with hands on his iliac crest with shoulders in abduction (as seen in picture)

Buddy taping of toes

• Secure the fractured toe to the adjacent toe with adhesive strips

• Sheet wadding between toes prevents maceration

Posterior Leg Splint

• This splint is used for:• Distal leg fractures• Ankle fractures • Tarsal fractures• Metatarsal fractures

Stirrup Splint

• To prevent inversion or eversion of the ankle

• Immobilizes the ankle for fractures near the ankle

• Apply from below the knee and wrap around the ankle

Thumb Spica Splint

• This splint is used for :• Scaphoid fractures• Extraarticular

fractures of the thumb• Ulnar collateral

ligament injuries

What do you do after you have applied your splint???

1.Have MD/PA evaluate splint

2.Document what you have done!!!

Documentation

• Which Splint you applied

• Which extremity you applied the splint to

• 6 P’s• Time you applied the

splint

• Condition of any wound

• How the patient tolerated the procedure

• Which MD/PA evaluated splint and time

Application of Splints

• Follow up on the floor and perform the following splints under the observation of your preceptor

• Gutter splint• Volar splint• Thumb Spica• Posterior leg splint• Stirrup leg splint• Clavicle Brace

Cast Care Introduction

• The function of a cast is to rigidly protect an injured bone or joint. It serves to hold the broken bone in proper alignment to prevent it from moving while it heals.

• Casts may also be used to help rest a bone or joint to relieve pain that is caused by moving it (such as when a severe sprain occurs, but no broken bones).

• Different types of casts and splints are available, depending on the reason for the immobilization and/or the type of fracture.

• Casts are usually made of either plaster or fiberglass material.

Fracture Types and Healing • A fractured bone is the same as a broken bone. Most fractures happen

because of a single and sudden injury. The diagnosis of a fracture is usually made with an x-ray film.

– A simple (or closed) fracture has intact skin over the broken bone. – An open fracture is also called a compound fracture. This means that a cut or

wound exists on the skin near the broken bone. If the cut is very severe, the edges of the bone may be seen coming out from the wound. 

– A stress fracture can result from many repeated small stresses on a bone. Microscopic fractures form and, if not given time to heal, can join to form a stress fracture. These types of fractures are usually seen in athletes or soldiers who perform repetitive vigorous activities.

– A pathologic fracture happens with minimal or no injury to an abnormal bone. This is usually caused by an underlying weakness or problem with the bone itself, such as osteoporosis or tumor.

• When a bone is fractured, it may require a reduction or realignment to put the ends of the fracture back into place. A doctor will do this by moving the fractured bone into alignment with his or her hands. If a bone has a fracture but is not out of position or deformed, no reduction is necessary.

• When the ends of the bone are aligned, the injured bone requires support and protection while it heals. A cast or splint usually provides this support and protection.

• Many factors affect the rate at which a fracture heals and the amount of time a person needs to wear a cast. Ask a doctor how much time the specific fracture will take to heal.

• Airplane Cast

Humerous and shoulder joint with compound fracture

Types of Casts and its Indication

Basket Cast Severe leg trauma with open

wound or inflammatin

Body Cast Lower dorso-lumbar spine

affection

Boot Leg Cast Hip and femoral fracture

Cast Brace Fracture of the femur (distal

curve) with flexion and extension

Collar Cast Cervical affection

Cylindrical Leg Cast Fractured patella

Double Hip Spica Mold Cervical affection with callus

formation

Frog Cast Congenital hip dislocation

Functional Cast Fractured humerous with

abduction and adduction

Hanging Cast Fractured shaft of the humerous

Internal Rotator Splintpost hip operation

Long Arm Circular Cast Fractured radius and ulna

How Casts Are Applied• Cast application

– Before casting material is applied (plaster or fiberglass), a "stockinette" is usually placed on the skin where the cast begins and ends (at the hand and near the elbow for a wrist cast). This stockinette protects the skin from the casting material.

– After the stockinette is placed, soft cotton batting material (also called cast padding or Webril) is rolled on. This cotton batting layer provides both additional padding to protect the skin and elastic pressure to the fracture to aid in healing.

– Next, the plaster or fiberglass cast material is rolled on while it is still wet. – The cast will usually begin to feel hard about 10-15 minutes after it is put on, but it takes much longer to

be fully dry and hard. – Be especially careful with the cast for the first 1-2 days because it can easily crack or break while it is

drying and hardening. It can take up to 24-48 hours for the cast to completely harden. • Plaster casts

– A plaster cast is made from rolls or pieces of dry muslin that have starch or dextrose and calcium sulfate added.

– When the plaster gets wet, a chemical reaction happens (between the water and the calcium sulfate) that produces heat and eventually causes the plaster to set, or get hard, when it dries.

– A person can usually feel the cast getting warm on the skin from this chemical reaction as it sets. . – Plaster casts are usually smooth and white.

• Fiberglass casts – Fiberglass casts are also applied starting from a roll that gets wet. – After the roll gets wet, it is rolled on to form the cast. Fiberglass casts also get warm and harden as they

dry. • Fiberglass casts are rough on the outside and look like a weave when they dry. Some

fiberglass casts may even be colored

Nursing Care• Handle wet cast with palms of the hands, not the fingers. Doing

so may cause flattering or indentions in the cast that might cause pressure problems.

• Cast should be allowed to air dry. • Elevate the cast on one to two pillows during drying. • Observe ‘hot spot” and musty color. These are signs and

symptoms of infection. • Maintain skin integrity. • Do neurovascular checks:

– Skin color – Skin temperature – Sensation – Mobility – Pulse

• Assess for vascular occlusion • Adhesive tape petals reduce irritation at cast edges.

Cast Care Instruction• Keep the cast clean and dry • Check for cracks or breaks in the cast• Rough edges can be padded to protect the skin from scratches• Do not scratch the skin under the cast by inserting objects inside the cast • Can use a hairdryer placed on a cool setting to blow air under the cast and

cool down the hot, itchy skin. Never blow warm or hot air into the cast • Do not put powders or lotion inside the cast • Cover the cast while your child is eating to prevent food spills and crumbs

from entering the cast• Prevent small toys or objects from being put inside the cast • Elevate the cast above the level of the heart to decrease swelling• Encourage your child to move his/her fingers or toes to promote circulation • Do not use the abduction bar on the cast to lift or carry the child.

Ice and Elevation

• A doctor may want the person to use ice to help decrease the swelling of the injured body part. (Check with a physician before using ice.)

• To keep the cast from becoming wet, put ice inside a sealed plastic bag and place a towel between the cast and the bag of ice.

• Apply ice to the injury for 15 minutes each hour (while awake) for the first 24-48 hours.

• Try to keep the cast and injured body part elevated above the level of the heart, especially for the first 48 hours after the injury occurs.

• Elevation will help to decrease the swelling and pain at the site of the injury.

• Propping the cast up on several pillows may be necessary to help elevate the injured area, especially while asleep.

How a Cast Is Removed• Do not try to remove the cast. • When it is time to remove the cast, the doctor will take it off with a cast saw and a

special tool. – A cast saw is a specialized saw made just for taking off casts. It has a flat and rounded metal

blade that has teeth and vibrates back and forth at a high rate of speed. – The cast saw is made to vibrate and cut through the cast but not to cut the skin underneath. – After several cuts are made in the cast (usually along either side), it is then spread and

opened with a special tool to lift the cast off. – The underlying layers of cast padding and stockinette are then cut off with scissors.

• After a cast is removed, depending on how long the cast has been on, the underlying body part may look different than the other uninjured side.

– The skin may be pale or a different shade. – The pattern and length of hair growth may also be different. – The injured part may even look smaller or thinner than the other side because some of the

muscles have weakened and have not been used since the cast was put on. • If the cast was over a joint, the joint is likely to be stiff. It will take some time and

patience before the joint regains its full range of motion.

Complications• Many potential complications are related not only to wearing a cast but also to

the healing of the underlying fracture. • Immediate complications• Compartment syndrome

– Compartment syndrome is a very serious complication that can happen because of a tight cast or a rigid cast that restricts severe swelling.

– Compartment syndrome happens when pressure builds within a closed space that cannot be released. This elevated pressure can cause damage to the structures inside that closed space or compartment—in this case, the muscles, nerves, blood vessels, and other tissues under the cast.

– This syndrome can cause permanent and irreversible damage if it is not discovered and corrected in time.

– Signs of compartment syndrome

• Severe pain • Numbness or tingling • Cold, pale, or blue-colored skin • Difficulty moving the joint or fingers and toes below the affected area. 

 

– If any of these symptoms occur, call the doctor right away. The cast may need to be loosened or replaced.  

• A pressure sore or cast sore can develop on the skin under the cast from excessive pressure by a cast that is too tight or poorly fitted.

When to Call Your Doctor• Check the cast and the skin around the edges of the

cast everyday. Look for any damage to the cast, or any red or sore areas on the skin.

• Call the doctor immediately if any of the following happen: – The cast gets wet, damaged, or breaks. – Skin or nails on the fingers or toes below the cast become

discolored, such as blue or gray. – Skin, fingers, or toes below the cast are numb, tingling, or

cold. – The swelling is more than before the cast was put on. – Bleeding, drainage, or bad smells come from the cast.

• Severe or new pain occurs

Thank you