splints and casts- indications and methods

Splints and Casts: Indications and MethodsANNES.BOYD,MD,University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania

HOLLYJ.BENJAMIN,MD,University of Chicago, Chicago, Illinois

CHADASPLUND,MD,The Ohio State University College of Medicine, Columbus, Ohio

Family physicians often make deci-sions about the use of splints andcastsinthemanagementofmuscu-loskeletaldisorders.Becauseofthis,

they need to be familiar with indicationsfor application, proper technique, and thepotentialpitfallsofcastingandsplintingtooptimize patient care when treating com-monorthopedicinjuries.

Splints and casts immobilize musculo-skeletalinjurieswhilediminishingpainandpromoting healing; however, they differ intheirconstruction,indications,benefits,andrisks. When determining whether to applya splintora cast, thephysicianmustmakean accurate diagnosis, as well as assess thestage,severity,andstabilityoftheinjury;thepatient’s functional requirements; and theriskofcomplications(Table 1).1,2

Because splints are noncircumferentialimmobilizers and are, therefore, more for-giving, they allow for swelling in the acutephase. Splinting is useful for a variety ofacute orthopedic conditions such as frac-tures, reduced joint dislocations, sprains,severesofttissueinjuries,andpost-lacerationrepairs.Thepurposeofsplintingacutelyistoimmobilizeandprotecttheinjuredextrem-ity,aidinhealing,andlessenpain.Splinting

during the later phases of injury or forchronic conditions will assist with healing,long-term pain control, and progression ofphysical function, and itwill slowprogres-sionofthepathologicprocess.3,4

Casting involves circumferential applica-tion of plaster or fiberglass to an extrem-ity. Casts provide superior immobilization,butare less forgivingandhavehighercom-plication rates. Therefore, they are usuallyreserved forcomplexand/ordefinitive frac-turemanagement.

Application of any immobilizer comeswith potential complications, includingischemia, heat injury, pressure sores, skinbreakdown, infection, dermatitis, neuro-logic injury, and compartment syndrome.These conditions can occur regardless ofhow longthedevice isused.5Tomaximizebenefits while minimizing complications,theuseofcastsandsplintsisgenerallylim-ited to the short term. Excessive immobi-lization from continuous use of a cast orsplint can lead to chronic pain, joint stiff-ness, muscle atrophy, or more severe com-plications, such as complex regional painsyndrome.6Allpatientswhoareplacedinasplintorcastrequirecarefulmonitoringtoensureproperrecovery.7

Management of a wide variety of musculoskeletal conditions requires the use of a cast or splint. Splints are noncircum-ferential immobilizers that accommodate swelling. This quality makes splints ideal for the management of a variety of acute musculoskeletal conditions in which swelling is anticipated, such as acute fractures or sprains, or for initial stabilization of reduced, displaced, or unstable fractures before orthopedic intervention. Casts are circumferential immobilizers. Because of this, casts provide superior immobilization but are less forgiving, have higher complication rates, and are generally reserved for complex and/or definitive fracture management. To maximize benefits while minimizing complications, the use of casts and splints is generally limited to the short term. Excessive immobiliza-tion from continuous use of a cast or splint can lead to chronic pain, joint stiffness, muscle atrophy, or more severe complications (e.g., complex regional pain syndrome). All patients who are placed in a splint or cast require careful monitoring to ensure proper recovery. Selection of a specific cast or splint varies based on the area of the body being treated, and on the acuity and stability of the injury. Indications and accurate application techniques vary for each type of splint and cast commonly encountered in a primary care setting. This article highlights the different types of splints and casts that are used in various circumstances and how each is applied. (Am Fam Physician. 2009;80(5):491-499. Copyright © 2009 American Academy of Family Physicians.)

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Splints and Casts

492 American Family Physician www.aafp.org/afp Volume 80, Number 5 ◆ September 1, 2009

Cast/Splint Choice and ApplicationThis article highlights the different types of splints andcaststhatareusedinvariouscircumstancesandhoweachisapplied.InapreviousarticleinAmerican Family Physician, wediscussedtheprinciplesandrisksofcastingandsplint-ing,aswellaspropertechniquesforsafeapplication.6

Castingandsplintingbothbeginbyplacingtheinjuredextremityinitspositionoffunction.Castingcontinueswith application of stockinette, then circumferentialapplicationoftwoorthreelayersofcottonpadding,andfinally circumferential application of plaster or fiber-glass.Ingeneral,2-inchpaddingisusedforthehands,2- to 4-inch padding for the upper extremities, 3-inchpadding for the feet, and 4- to 6-inch padding for thelowerextremities.

Splinting may be accomplished in a variety of ways.Oneoptionistobeginasifcreatingacastand,withthe

extremityinitspositionoffunction,applystockinette,thenalayerofoverlappingcircumferentialcottonpad-ding.Thewetsplintisthenplacedoverthepaddingandmoldedtothecontoursoftheextremity,andthestocki-netteandpaddingarefoldedbacktocreateasmoothedge(Figure 1).Thedriedsplintissecuredinplacebywrap-pinganelasticbandageinadistaltoproximaldirection.For an average-size adult, upper extremities should besplintedwithsixto10sheetsofcastingmaterial,whereaslowerextremitiesmayrequire12to15sheets.

Anacceptablealternativeistocreateasplintwithouttheuseofstockinetteorcircumferentialpadding.Sev-erallayersofpaddingthatareslightlywiderandlongerthanthesplintareapplieddirectlytothesmoothed,wetsplint.Together theyaremolded to the extremityandsecuredwithanelasticbandage(Figure 2).Prepackagedsplintsconsistingoffiberglassandpaddingwrappedina

Table 1. Comparison of Splints and Casts

Splint/cast Construction Indications Advantages Risks/disadvantages

Splint Noncircumferential Acute and definitive treatment of select fractures

Soft tissue injuries (sprains, tendons)

Acute management of injuries awaiting orthopedic intervention

Allows for acute swelling

Decreased risk of complications

Faster and easier application

Commercial splints available and appropriate for select injuries

May be static (preventing motion) or dynamic (functional; assisting with controlled motion)

Lack of compliance

Increased range of motion at injury site

Not useful for definitive care of unstable or potentially unstable fractures

Cast Circumferential Definitive management of simple, complex, unstable, or potentially unstable fractures

Severe, nonacute soft tissue injuries unable to be managed with splinting

More effective immobilization Higher risk of complications

More technically difficult to apply

Information from references 1 and 2.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence rating References Comments

Use of a short arm radial gutter splint is recommended for initial immobilization of a displaced distal radial fracture.

B 11 RCT

Immobilization of the thumb with a removable splint after a ligamentous injury is strongly preferred by patients, and the functional results are equal to those of plaster cast immobilization after surgical and nonsurgical treatment.

B 12 RCT

Removable splinting is preferable to casting in the treatment of wrist buckle fractures in children. B 13 RCT

Evidence supports a functional treatment approach to inversion ankle sprains with the use of a semirigid or soft lace-up brace.

B 17 Systematic review

RCT = randomized controlled trial.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.xml.

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September 1, 2009 ◆ Volume 80, Number 5 www.aafp.org/afp American Family Physician 493

meshlayeralsoexist.Theseareeasilycutandmoldedtotheinjuredextremity;however,theyaremoreexpensiveand are not always available. Prefabricated and over-the-counter splints are the simplest option, althoughtheyareless“customfit,”andtheirusemaybelimitedbycostoravailability.

The most common types of splints and casts usedin primary care, with information on indications andfollow-up,arediscussedinTables 2 through 4. Allsplintsaredescribedbeforeelasticbandageapplication.

gENERAl FRACTuRE MANAgEMENT PRINCIPlES

Itisimportanttomaintaingoodanatomicfracturealign-ment throughout treatment.Acceptable angulardefor-mityinthehandvariesdependingonthefracturesite.Rotationaldeformityinthehandisneveracceptable.

Stablefracturesaregenerallyreevaluatedwithinonetotwoweeksfollowingcastapplicationtoassesscastfitandcondition,andtoperformradiographytomonitorheal-ingandfracturealignment.Handandforearmfractures,however,areoftenreevaluatedwithinthefirstweek.

Displacedfracturesrequireclosedreduction,followedby post-reduction radiography to confirm bone align-ment.Bothdisplacedandunstablefracturesshould be monitored vigilantly to ensuremaintainedpositioning.Ifreductionorposi-tioningisnotmaintained,urgentreferraltoanorthopedicsubspecialistiswarranted.8-10

upper Extremity Splints and CastsulNAR guTTER SPlINT

Common Uses. Nondisplaced,stablefracturesof thehead,neck,andshaftof the fourthorfifthmetacarpalwithmildangulationandnorotational deformities; nondisplaced, non-rotatedshaftfracturesandserioussofttissueinjuries of the fourth or fifth, proximal ormiddlephalanx;boxer’sfractures(distalfifthmetacarpalfractures,themostcommoninjuryforwhichulnarguttersplint/castused).

Application. Thesplintbeginsattheproxi-malforearmandextendstojustbeyondthedistalinterphalangeal(DIP)joint(Figure 1).Castpaddingisplacedbetweenthefingers.

Position of Function. The wrist is slightly extended,with the metacarpophalangeal (MCP) joints in 70 to90degreesofflexion,andtheproximalinterphalangeal(PIP)andDIPjointsin5to10degreesofflexion.

ulNAR guTTER CAST

Common Uses. Definitive or alternative treatment ofinjuriescommonlytreatedwithulnarguttersplint.8

Application. Ideally,thecastisapplied24to48hoursormoreaftertheinitialinjurytoallowswellingtodecrease.Placementof the castingmaterials is similar to thatoftheulnarguttersplint,excepttheplasterorfiberglassiswrappedcircumferentially(Figure 3).

RADIAl guTTER SPlINT

Common Uses. Nondisplacedfracturesofthehead,neck,and shaft of the second or third metacarpal withoutangulation or rotation; nondisplaced, nonrotated shaftfractures and serious injuries of the second or third,proximal or middle phalanx; initial immobilization ofdisplaceddistalradiusfractures.11

Application. The splint runs along the radial aspectoftheforearmtojustbeyondtheDIPjointoftheindex

Figure 1. Ulnar gutter splint with underlying stockinette and circumferential padding. Figure 2. Padded thumb spica splint.

Table 2. Commonly used Splints and Casts

Area of injury Type of splint Type of cast

Hand/finger Ulnar gutter, radial gutter, thumb spica, finger

Ulnar gutter, radial gutter, thumb spica

Forearm/wrist Volar/dorsal forearm, single sugar-tong

Short arm, long arm

Elbow/forearm Long arm posterior, double sugar-tong

Long arm

Knee Posterior knee, off-the-shelf immobilizer

Long leg

Tibia/fibula Posterior ankle (mid-shaft and distal fractures), bulky Jones

Long leg (proximal fracture), short leg (mid-shaft and distal)

Ankle Posterior ankle (“post-mold”), stirrup, bulky Jones, high-top walking boot

Short leg

Foot

Posterior ankle with or without toe box, hard-soled shoe, high-top walking boot

Short leg, short leg with toe box for phalanx fracture

Splints and Casts


Table 3. upper Extremity Splinting and Casting Chart

RegionType of splint/cast Indications Pearls/pitfalls Follow-up/referral

Ulnar side of hand

Ulnar gutter splint/cast

Fourth and fifth proximal/middle phalangeal shaft fractures and select metacarpal fractures

Proper positioning of MCP joints at 70 to 90 degrees of flexion, PIP and DIP joints at 5 to 10 degrees of flexion

One to two weeks

Refer for angulated, displaced, rotated, oblique, or intra-articular fracture or failed closed reduction

Radial side of hand

Radial gutter splint/cast

Second and third proximal/middle phalangeal shaft fractures and select metacarpal fractures

Proper positioning of MCP joints at 70 to 90 degrees of flexion, PIP and DIP joints at 5 to 10 degrees of flexion

One to two weeks

Refer for angulated, displaced, rotated, oblique, or intra-articular fracture or failed closed reduction

Thumb, first metacarpal, and carpal bones

Thumb spica splint/cast

Injuries to scaphoid/trapezium

Nondisplaced, nonangulated, extra-articular first metacarpal fractures

Stable thumb fractures with or without closed reduction

Fracture of the middle/proximal one third of the scaphoid treated with casting

One to two weeks

Refer for angulated, displaced, intra-articular, incompletely reduced, or unstable fracture

Refer displaced fracture of the scaphoid

Finger injuries Buddy taping Nondisplaced proximal/middle phalangeal shaft fracture and sprains

Encourage active range of motion in all joints

Two weeks

Refer for angulated, displaced, rotated, oblique, or significant intra-articular fracture or failure to regain full range of motion

Aluminum U-shaped splint

Distal phalangeal fracture Encourage active range of motion at PIP and MCP joints

Dorsal extension-block splint

Middle phalangeal volar plate avulsions and stable reduced PIP joint dislocations

Increase flexion by 15 degrees weekly, from 45 degrees to full extension

Buddy taping permitted with splint use

Mallet finger splint

Extensor tendon avulsion from the base of the distal phalanx

Continuous extension in the splint for six to eight weeks is essential

Wrist/hand Volar/dorsal forearm splint

Soft tissue injuries to hand and wrist

Acute carpal bone fractures (excluding scaphoid/trapezium)

Childhood buckle fractures of the distal radius

Consider splinting as definitive treatment for buckle fractures

One week

Refer for displaced or unstable fractures

Refer lunate fractures

Short arm cast Nondisplaced, minimally displaced, or buckle fractures of the distal radius

Carpal bone fractures other than scaphoid/trapezium

Forearm Single sugar-tong splint

Acute distal radial and ulnar fractures

Used for increased immobilization of forearm and greater stability

Less than one week


Elbow, proximal forearm, and skeletally immature wrist injuries

Long arm posterior splint, long arm cast

Distal humeral and proximal/midshaft forearm fractures

Nonbuckle wrist fractures

Ensure adequate padding at bony prominences

Within one week


Double sugar-tong splint

Acute elbow and forearm fractures, and nondisplaced, extra-articular Colles fractures

Offers greater immobilization against pronation/supination

Less than one week

Refer childhood distal humeral fractures

DIP = distal interphalangeal; MCP = metacarpophalangeal; PIP = proximal interphalangeal.

Splints and Casts


finger,leavingthethumbfree(Online Figure A).Castpaddingisplacedbetweenthefingers.

Position of Function. The wrist is placed in slightextension,with theMCPjoints in70 to90degreesofflexion,andthePIPandDIPjoints in5to10degreesofflexion.

RADIAl guTTER CAST

Common Uses. Definitive or alternative treatment offracturesinitiallymanagedwitharadialguttersplint.

Application. Placementofthecastingmaterialsissimi-lartothatoftheradialguttersplint,excepttheplaster

orfiberglassiswrappedcircumferentially(Figure 4).Thecastisusuallyplacedtwotosevendaysaftertheinitialinjurytoallowforresolutionofswelling.

Pearls and Pitfalls. Minimalangulationorrotationatthefracturesitemaycausefunctionalproblems,suchasdifficulty with grasp, pinch, or opposition. Therefore,meticulousevaluationandfollow-upareessential.

ThuMb SPICA SPlINT

Common Uses. Suspectedinjuriestothescaphoid;stableligamentousinjuriestothethumb;initialtreatmentofnonangulated, nondisplaced, extra-articular fractures

Table 4. lower Extremity Splinting and Casting Chart

Region Type of splint/cast Indications Pearls/pitfalls Follow-up/referral

Ankle Posterior ankle splint (“post-mold”)

Severe sprains

Isolated, nondisplaced malleolar fractures

Acute foot fractures

Splint ends 2 inches distal to fibular head to avoid common peroneal nerve compression

Less than one week

Refer for displaced or multiple fractures or significant joint instability

Ankle Stirrup splint Ankle sprains

Isolated, nondisplaced malleolar fractures

Mold to site of injury for effective compression

Less than one week

Lower leg, ankle, and foot

Short leg cast Isolated, nondisplaced malleolar fractures

Foot fractures—tarsals and metatarsals

Compartment syndrome most commonly associated with proximal mid-tibial fractures, so care is taken not to over-compress

Weight-bearing status important; initially non–weight bearing with tibial injuries

Two to four weeks

Refer for displaced or angulated fracture or proximal first through fourth metatarsal fractures

Knee and lower leg

Posterior knee splint

Acute soft tissue and bony injuries of the lower extremity

If ankle immobilization is necessary, as with tibial shaft injuries, the splint should extend to include the metatarsals

Days

Foot

Short leg cast with toe plate extension

Distal metatarsal and phalangeal fractures

Useful technique for toe immobilization

Often used when high-top walking boots are not available

Two weeks


Figure 3. Ulnar gutter cast. Figure 4. Radial gutter cast.

Splints and Casts


ofthebaseofthefirstmetacarpal;deQuervaintenosy-novitis;firstcarpometacarpaljointarthritis.

Application. Thesplintcoverstheradialaspectoftheforearm, from the proximal one third of the forearmtojustdistaltotheinterphalangealjointofthethumb,encirclingthethumb(Figure 2).

Position of Function. Theforearmisintheneutralposi-tionwiththewristextendedto25degreesandthethumbinapositionoffunction(i.e.,“holdingasodacan”).

Pearls and Pitfalls. Immobilizationofthethumbwitharemovablesplintafteraligamentousinjuryisstronglypreferredbypatients,andthefunctionalresultsareequaltothoseofplastercastimmobilizationaftersurgicalandnonsurgicaltreatment.12

ThuMb SPICA CAST

Common Uses. Suspected or nondisplaced, distal frac-turesofthescaphoid;nonangulated,nondisplaced,extra-articularfracturesofthebaseofthefirstmetacarpal.

Application. Thecastusesthesamepositionoffunctionasdescribedforathumbspicasplint,butrequirescircum-ferentialapplicationofcastingmaterials(Figure 5).

Pearls and Pitfalls. Becausethesetypesoffracturesareoftenseriousandhaveahighrateofcomplications,long-termsplintingisnotanappropriatedefinitivetreatment.Angulated, displaced, incompletely reduced, or intra-articularfracturesofthefirstmetacarpalbaseshouldbereferred for orthopedic subspecialist evaluation.8 Non-displaceddistalfracturesofthescaphoidhaveagreaterpotentialtohealandmaybeplacedinashortarmthumbspicacastandreevaluatedoutofthecastbyradiographyin two weeks.2,9 Nondisplaced fractures of the middleorproximalonethirdofthescaphoidaretreatedwithalongarmthumbspicacastinitiallyandrequirevigilantmonitoringfornonunion.2

buDDY TAPINg (DYNAMIC SPlINTINg)

Common Uses. Minor finger sprains; stable, nondis-placed,nonangulatedshaftfracturesoftheproximalormiddlephalanx.7,8

Application. Theinjuredfingeristapedtotheadjacentfingerforprotectionandtoallowmovement(Online Figure B).

DORSAl ExTENSION-blOCK SPlINT

Common Uses. Larger,middlephalangealvolaravulsionswithpotentialfordorsalsubluxation;reduced,stablePIPjointdorsaldislocations.

Application. Inreduced,volaravulsion fractures, thesplintisappliedwiththePIPjointat45degreesofflexionand secured at the proximal finger, allowing flexion at

thePIPjoint(Figure 6).Withweeklylateralradiography,the flexion is decreased 15 degrees until reaching fullextensionoverfourweeks.Buddytapingshouldfollow.Treatment of reduced PIP joint dislocations is similar,butrequiresastartingangleof20degrees.

AluMINuM u-ShAPED SPlINT

Common Uses.Distalphalangealfractures.Application. Thealuminumsplintwrapsfromthedor-

salfingertiparoundtothevolarfingertipandimmobilizesonlytheDIPjointinextension(Online Figure C).

MAllET FINgER SPlINTS

Common Uses. Avulsionoftheextensortendonfromthebaseofthedistalphalanx(withorwithoutanavulsionfracture).

Figure 5. Thumb spica cast.

Figure 6. Dorsal extension-block splint.

Splints and Casts


Application. TheDIPjointisplacedinslighthyperex-tensionwithapaddeddorsalsplint,anunpaddedvolarsplint,oraprefabricatedmalletfingersplint.Continuousextensioninthesplintforsixtoeightweeksisessential,evenwhenchangingthesplint.Compliance isassessedeverytwoweeks.Nightsplintingforanadditionaltwotothreeweeksisrecommended.

vOlAR/DORSAl FOREARM SPlINT

Common Uses. Softtissueinjuriesofthehandandwrist;temporary immobilization of carpal bone dislocationsorfractures(excludingscaphoidandtrapezium).

Application. Thesplintextendsfromthedorsalorvolarmid-forearmtothedistalpalmarcrease(Figure 7).

Position of Function. Thewristisslightlyextended.Pearls and Pitfalls. Thesplintdoesnot limit forearm

pronation and supination, and is generally not recom-mended for distal radial or ulnar fractures. A recentstudy,however,demonstratedthatcomparedwithcast-

ingfordefinitivetreatmentofwristbucklefracturesinchildren, a removable plaster splint improves physicalfunctioningandsatisfaction,withnodifferenceinpainorhealingrates.13

ShORT ARM CAST

Common Uses. Nondisplaced or minimally displacedfractures of the distal wrist, such as Colles and Smithfracturesorgreenstick,buckle,andphysealfracturesinchildren; carpalbone fracturesother than scaphoidortrapezium.

Application. ThecastextendsfromtheproximalonethirdoftheforearmtothedistalpalmarcreasevolarlyandjustproximaltotheMCPjointsdorsally(Online Figure D).

Position of Function. Thewristisinaneutralpositionandslightlyextended;theMCPjointsarefree.

Pearls and Pitfalls. Thesearethesameasforaforearmsplint.

SINglE SugAR-TONg SPlINT

Common Uses. Acute management of distal radial andulnarfractures.

Application. Thesplintextendsfromtheproximalpal-marcrease,alongthevolarforearm,aroundtheelbowtothedorsumoftheMCPjoints(Figure 8).

Position of Function. The forearm is neutral and thewristisslightlyextended.

Pearls and Pitfalls. Thesplintstabilizesthewristelbowand limits,butdoesnoteliminate, forearmsupinationandpronation.

lONg ARM POSTERIOR SPlINT

Common Uses. Acute and definitive management ofelbow,proximalandmid-shaftforearm,andwristinju-ries;acutemanagementofdistalradial(nonbuckle)and/orulnarfracturesinchildren.

Application. The splint extends from the axilla overtheposteriorsurfaceofthe90-degreeflexedelbow,andalongtheulnatotheproximalpalmarcrease(Online Figure E).

Pearls and Pitfalls. The posterior splint is not recom-mendedforcomplexorunstabledistalforearmfractures.

lONg ARM CAST

Common Uses. Definitive treatmentof injuries initiallytreatedwithaposteriorsplint.

Application. Thecastextendsfromthemid-humerustothedistalpalmarcreasevolarlyandjustproximaltotheMCPjointsdorsally.

Position of Function. Theelbowisflexedto90degrees

Figure 7. Volar wrist splint.

Figure 8. Single sugar-tong splint.

Splints and Casts


withthewristinaneutral,slightlyextendedposition(Online Figure F).

Pearls and Pitfalls. Adequate padding at the olecra-non, ulnar styloid, and antecubital fossa prevents skinbreakdown. Physicians should avoid applying the edgeofthecastingtapeovertheantecubitalfossa,particularlywiththeinitiallayer.Longarmcastsareusedmostoftenin childhood because of the frequency of distal radial,ulnar,anddistalhumeralfractures.2,10,14

DOublE SugAR-TONg SPlINT

Common Uses. Acutemanagementofelbowandforearminjuries,includingCollesfractures.

Application. Physiciansshouldstartbyplacingasinglesugar-tongsplint,asdescribedabove(Figure 8).Asecondsugar-tongsplintisthenapplied,extendingfromthedel-toidinsertiondistallyaroundthe90-degreeflexedelbow,andproximallyto3inchesshortoftheaxilla(Figure 9).

Pearls and Pitfalls. The splint provides superior pro-nation and supination control, and is preferable withcomplexorunstablefracturesofthedistalforearmandelbow.

lower Extremity Splints and CastsPOSTERIOR ANKlE SPlINT (“POST-MOlD”)

Common Uses. Acute,severeanklesprain;nondisplaced,isolatedmalleolarfractures;acutefootfracturesandsofttissueinjuries.

Application. Thesplintextendsfromtheplantarsur-faceofthegreattoeormetatarsalheadsalongtheposte-riorlowerlegandends2inchesdistaltothefibularhead

toavoidcompressionofthecommonperonealnerve(Online Figure G).

Pearls and Pitfalls. Forefficientapplication,thepatientshouldbeplacedinapronepositionwiththekneeandankleflexedto90degrees.15,16

STIRRuP SPlINT

Common Uses. Acuteankle injuries;nondisplaced, iso-latedmalleolarfractures.

Application. Thesplintextendsfromthelateralmid-calf around the heel, and ends at the medial mid-calf

(Online Figure H).16Thepositionoffunctioniswiththeankleflexedto90degrees(neutral).

Pearls and Pitfalls. Stirrupandposterioranklesplintsprovide comparable ankle immobilization. Althoughthe stirrup splint is adequate for short-term treatmentofacuteanklesprains,theevidencefavorsafunctionalapproach to inversion ankle sprain treatment with theuseofasemirigidorsoftlace-upbrace.17

AbulkyJonessplintisavariationonthestirrupsplint

used acutely for more severe ankle injuries. The lowerextremityiswrappedwithcottonbattingandreinforcedwithastirrupsplint,providingcompressionandimmo-bilizationwhileallowingforconsiderableswelling.16

ShORT lEg CAST

Common Uses. Definitive treatment of injuries to theankleandfoot.

Application. The cast begins at the metatarsal headsandends2inchesdistaltothefibularhead.Additionalpaddingisplacedoverbonyprominences,includingthefibularheadandbothmalleoli(Online Figure I).

Position of Function. Theankleisflexedto90degrees(neutral).

Pearls and Pitfalls. Weight-bearingrecommendationsaredeterminedbythetypeandstabilityoftheinjuryandthepatient’scapacityanddiscomfort.Shortlegwalkingcastsareadequatefornondisplacedfibularandmetatar-salfractures.2,18Commerciallyproducedhigh-topwalk-ingbootsareacceptablealternatives for injuriesat lowriskofcomplications.2,19

TOE PlATE ExTENSIONS

Common Uses. Toe immobilization (comparable to ahigh-top walking boot or cast shoe); distal metatarsalandphalangealfractures,particularlyofthegreattoe.

Application. Aplateismadebyextendingthecastingmaterialbeyondthedistaltoes,prohibitingplantarflex-ionandlimitingdorsiflexion(Figure 10).2,19

Pearls and Pitfalls. The cast must be molded to themediallongitudinalarchwiththeankleat90degreestoallowforsuccessfulambulation.

POSTERIOR KNEE SPlINT

Common Uses. Stabilizationofacutesofttissueinjuries(e.g., quadriceps or patellar tendon rupture, anteriorcruciate ligament rupture), patellar fracture or dislo-cation, and other traumatic lower extremity injuries,particularlywhenakneeimmobilizer isunavailableorunusablebecauseofswellingorthepatient’ssize.

Application. The splint should start just below the

Figure 9. Double sugar-tong splint.

Splints and Casts


glutealcreaseandend justproximal tothemalleoli(Online Figure J).

Position of Function. Theknee ispositioned in slightflexion.

Pearls and Pitfalls. If ankle immobilization is neces-sary,aswithtibialshaftinjuries,thesplintshouldextendtoincludethemetatarsals.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Army or the U.S. Army Medical Service at large.

The Authors

ANNE S. BOYD, MD, FAAFP, is an assistant professor of family medicine at the University of Pittsburgh (Pa.) School of Medicine, and director of the primary care sports medicine fellowship program at the University of Pittsburgh Medical Center, St. Margaret.

HOLLY J. BENJAMIN, MD, FAAP, FACSM, is an associate professor of pediatrics and orthopedic surgery at the University of Chicago (Ill.), and director of the primary care sports medicine program. She serves on the board of directors for the American Medical Society for Sports Medicine, is part of the executive committee for the American Academy of Pediatrics Council on Sports Medicine and Fitness, and is a fellow of the American College of Sports Medicine.

CHAD ASPLUND, MD, is currently a clinical assistant professor of family medicine at The Ohio State University College of Medicine, Columbus. At the time this article was written, he was a clinical faculty member of the Eisenhower Army Medical Center in Fort Gordon, Ga.

Address correspondence to Anne S. Boyd, MD, FAAFP, Lawrenceville Family Health Center, 3937 Butler St., Pittsburgh, PA 15201. Reprints are not available from the authors.

Author disclosure: Nothing to disclose.

REFERENCES

1. Chudnofsky CR, Byers S. Splinting techniques. In: Roberts JR, Hedges JR, Chanmugam AS, eds. Clinical Procedures in Emergency Medicine. 4th ed. Philadelphia, Pa.: Saunders; 2004:989.

2. Eiff MP, Hatch R, Calmbach WL, eds. Fracture Management for Primary Care. 2nd ed. Philadelphia, Pa.: Saunders; 2003:1-70.

3. Parmelee-Peters K, Eathorne S. The wrist: common injuries and man-agement. Prim Care. 2005;32(1):35-70.

4. Hong E. Hand injuries in sports medicine. Prim Care. 2005;32(1):91-103.

5. General principles. In: Simon RR, Sherman SC, Koenigsknecht SJ, eds. Emergency Orthopedics: The Extremities. 5th ed. New York, NY: McGraw-Hill; 2007:1-29.

6. Boyd AS, Benjamin HJ, Asplund C. Principles of casting and splinting. Am Fam Physician. 2009;79(1):16-22.

7. Benjamin HJ, Mjannes JM, Hang BT. Getting a grasp on hand injuries in young athletes. Contemp Pediatr. 2008;25(3):49-63.

8. Lee SG, Jupiter JB. Phalangeal and metacarpal fractures of the hand. Hand Clin. 2000;16(3):323-332.

9. Slade JF, Magit DP, Geissler WB. Scaphoid fractures in athletes. Atlas Hand Clin. 2006;11(1):27-44.

10. Overly F, Steele DW. Common pediatric fractures and dislocations. Clin Pediatr Emerg Med. 2002;3(2):106.

11. Bong MR, Egol KA, Leibman M, Koval KJ. A comparison of immediate postreduction splinting constructs for controlling initial displacement of fractures of the distal radius: a prospective randomized study of long-arm versus short-arm splinting. J Hand Surg [Am]. 2006;31(5):766-770.

12. Sollerman C, Abrahamsson SO, Lundborg G, Adalbert K. Functional splinting versus plaster cast for ruptures of the ulnar collateral ligament of the thumb. A prospective randomized study of 63 cases. Acta Orthop Scand. 1991;62(6):524-526.

13. Plint AC, Perry JJ, Correll R, Gaboury I, Lawton L. A randomized, con-trolled trial of removable splinting versus casting for wrist buckle frac-tures in children. Pediatrics. 2006;117(3):691-697.

14. Benjamin HJ, Hang BT. Common acute upper extremity injuries in sports. Clin Pediatr Emerg Med. 2007;8(1):15-30.

15. Haller PR, Harris CR. The tibia and fibula. In: Ruiz E, Cicero JJ, eds. Emergency Management of Skeletal Injuries. St Louis, Mo.: Mosby-Year Book; 1995:499-517.

16. Roberts DM, Stallard TC. Emergency department evaluation and treatment of knee and leg injuries. Emerg Med Clin North Am. 2000;18(1):67-84.

17. Kerkhoffs GM, Struijs PA, Marti RK, Assendelft WJ, Blankevoort L, van Dijk CN. Different functional treatment strategies for acute lateral ankle ligament injuries in adults. Cochrane Database Syst Rev. 2002;(3):CD002938.

18. Court-Brown CM. Fractures of the tibia and fibula. In: Rockwood CA, Green DP, Buchholz RW, eds. Rockwood and Green’s Fractures in Adults. 6th ed. Philadelphia, Pa.: Lippincott Williams and Wilkins; 2006:2079-2146.

19. LaBella CR. Common acute sports-related lower extremity injuries in children and adolescents. Clin Pediatr Emerg Med. 2007;8(1):31-42.

Figure 10. Short leg cast with toe plate extension.

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