Care of Casts and Splints – OrthoInfo

Casts and splints support and protect injured bones and soft tissue. When you break a bone, your doctor will put the pieces back together in the right position. Casts and splints hold the bones in place while they heal. They also reduce pain, swelling, and muscle spasm.

In some cases, splints and casts are applied following surgery.

Splints or half-casts provide less support than casts. However, splints can be adjusted to accommodate swelling from injuries easier than enclosed casts. Your doctor will decide which type of support is best for you.

Casts are custom-made. They must fit the shape of your injured limb correctly to provide the best support. Casts can be made of plaster or fiberglass — a plastic that can be shaped.

Photos show a long-arm cast made of fiberglass with cotton lining.

Splints or half-casts can also be custom-made, especially if an exact fit is necessary. Other times, a ready-made splint will be used. These off-the-shelf splints are made in a variety of shapes and sizes and are much easier and faster to use. Some have Velcro straps which make the splints easy to put on, take off, and adjust.

To allow room for swelling, the rigid part of a splint or “half cast” (left) does not wrap all the way around the injured area. It is held in place with an elastic bandage or other material (right).

Materials

Fiberglass or plaster materials form the hard, supportive layer in splints and casts.

Fiberglass is lighter in weight and stronger than plaster. In addition, X-rays can see through fiberglass better than through plaster. This is important because your doctor will probably schedule additional X-rays after your splint or cast has been applied. X-rays can show whether the bones are healing well or have moved out of place.

Plaster is less expensive than fiberglass and shapes better than fiberglass for some uses.

Application

Both fiberglass and plaster splints and casts use padding, usually cotton, as a protective layer next to the skin. Both materials come in strips or rolls, which are dipped in water and applied over the padding covering the injured area. In some cases, special waterproof padding and cast material may be used. Your doctor will let you know if your cast is made and padded with these waterproof materials.

The splint or cast must fit the shape of the injured arm or leg correctly to provide the best possible support. Generally, the splint or cast also covers the joint above and below the broken bone.

In many cases, a splint is applied to a fresh injury first. As swelling subsides, a full cast may replace the splint. If a cast is initially applied to your injury, it may be “valved” (cut) to allow for swelling, then repaired at your first follow-up appointment.

Sometimes, it may be necessary to replace a cast as swelling goes down and the cast gets too big. As a fracture heals, the cast may be replaced by a splint to make it easier to perform physical therapy exercises.

Swelling due to your injury may cause pressure in your splint or cast for the first 48 to 72 hours. This may cause your injured arm or leg to feel snug or tight in the splint or cast. If you have a splint, your doctor will show you how to adjust it to accommodate the swelling.

It is very important to keep the swelling down. This will lessen pain and help your injury heal. To help reduce swelling:

• Elevate. It is very important to elevate your injured arm or leg for the first 24 to 72 hours. Prop your injured arm or leg up above your heart by putting it on pillows or some other support. You will have to recline if the splint or cast is on your leg. Elevation allows clear fluid and blood to drain “downhill” to your heart.
• Exercise. Move your uninjured, but swollen fingers or toes gently and often. Moving them often will prevent stiffness.
• Ice. Apply ice to the splint or cast. Place the ice in a dry plastic bag or ice pack and loosely wrap it around the splint or cast at the level of the injury. Ice that is packed in a rigid container and touches the cast at only one point will not be effective.

Apply ice to the splint or cast and elevate your leg to reduce swelling.

Swelling can create a lot of pressure under your cast. This can lead to problems. If you experience any of the following symptoms, contact your doctor’s office immediately for advice.

• Increased pain and the feeling that the splint or cast is too tight. This may be caused by swelling.
• Numbness and tingling in your hand or foot. This may be caused by too much pressure on the nerves.
• Burning and stinging. This may be caused by too much pressure on the skin.
• Excessive swelling below the cast. This may mean the cast is slowing your blood circulation.
• Loss of active movement of toes or fingers. This requires an urgent evaluation by your doctor.

To Top

Your doctor will explain any restrictions on using your injured arm or leg while it is healing. You must follow your doctor’s instructions carefully to make sure your bone heals properly. The following information provides general guidelines only and is not a substitute for your doctor’s advice.

After you have adjusted to your splint or cast for a few days, it is important to keep it in good condition. This will help your recovery.

• Keep your splint or cast dry. Moisture weakens plaster, and damp padding next to the skin can cause irritation. Use two layers of plastic or purchase waterproof shields to keep your splint or cast dry while you shower or bathe. Even if the cast is covered, do not submerge it or hold it under running water. A small pinhole in the cast cover can cause the injury to get soaked.
• Walking casts. Do not walk on a walking cast until it is completely dry and hard. It takes about 1 hour for fiberglass, and 2 to 3 days for plaster to become hard enough to walk on. You will be given a cast shoe to wear over your walking cast. The cast shoe will help protect the bottom of the cast.
• Avoid dirt. Keep dirt, sand, and powder away from the inside of your splint or cast.
• Padding. Do not pull out the padding from your splint or cast.
• Itching. Do not stick objects such as coat hangers inside the splint or cast to scratch itching skin. Do not apply powders or deodorants to itching skin. If itching persists, contact your doctor. If something gets stuck inside your cast, it may irritate your skin, so contact your doctor. 
• Trimming. Do not break off rough edges of the cast or trim the cast before asking your doctor.
• Skin. Inspect the skin around the cast. If your skin becomes red or raw around the cast, contact your doctor.
• Inspect the cast regularly. If it becomes cracked or develops soft spots, contact your doctor’s office.

Use common sense. You have a serious injury and you must protect your cast from damage so it can protect your injury while it heals.

After the initial swelling has subsided, proper splint or cast support will usually allow you to continue your daily activities with a minimum of inconvenience.

Never remove the cast yourself. You may cut your skin or prevent proper healing of your injury.

Your doctor will use a cast saw to remove your cast. The saw vibrates but does not rotate. If the blade of the saw touches the padding inside the hard shell of the cast, the padding will vibrate with the blade and will protect your skin. Cast saws make noise and may feel hot from friction, but they will not harm you — as the saying goes, their bark is worse than their bite.

If you do feel pain while the cast is being removed, let your doctor or an assistant know, and they will be able to make adjustments.

The saw vibrates but does not rotate. Cast saws make noise but will not harm you.

Broken bones take several weeks to several months to heal. Pain usually stops long before the bone is solid enough to handle the stresses of everyday activities. You will need to wear your cast or splint until your bone is fully healed and can support itself.

While you are wearing your cast or splint, you will likely lose muscle strength in the injured area. Exercises during the healing process and after your cast is removed are important. They will help you restore normal muscle strength, joint motion, and flexibility.

To Top

Reviewed by members of
POSNA (Pediatric Orthopaedic Society of North America)

The Pediatric Orthopaedic Society of North America (POSNA) is a group of board eligible/board certified orthopaedic surgeons who have specialized training in the care of children’s musculoskeletal health. 

Learn more about this topic at POSNA’s OrthoKids website:

Casts and Splints

Information on this topic is also available as an OrthoInfo Basics PDF Handout.

For more information:

Basics Handouts

Splinting – StatPearls – NCBI Bookshelf

Continuing Education Activity

Injuries that result in instability require immobilization, decreasing the likelihood of further damage, protecting soft tissues, alleviating pain, and accelerating healing. Instability may result from direct injury to the bones (fracture), joints (dislocation), or the soft tissues such as the muscles (strain) or ligaments (sprain). Following the diagnosis of an unstable injury, a splint may be the best treatment option and is loosely defined as an external device used to immobilize an injury or joint and is most often made out of plaster. A splint must be differentiated from a cast, to determine the best form of immobilization based on the clinical scenario. This activity remains the role of the healthcare team in assessing and applying splinting immobilization to injuries that will benefit from such a strategy.

Objectives:

• Identify the indications, and contraindications of splinting in the acute setting.

• Describe the equipment, personnel, preparation, and technique in regards to splinting common musculoskeletal injuries such as sprains, fractures, and soft tissue injuries.

• Review the potential complications of splinting for musculoskeletal injuries.

• Outline the interprofessional team strategies for improving care coordination and communication to improve splinting outcomes.

Access free multiple choice questions on this topic.

Introduction

Patients commonly present to emergency departments, primary care offices, or specialty clinics with musculoskeletal injuries. The initial management of an acute traumatic limb injury involves a thorough history and physical evaluation of the injury, which includes a motor, sensory, and neurovascular examination. Injuries that result in instability require immobilization, decreasing the likelihood of further damage, protecting soft tissues, alleviating pain, and accelerating healing. Instability may result from direct injury to the bones (fracture), joints (dislocation), or the soft tissues such as the muscles (strain) or ligaments (sprain). Following the diagnosis of an unstable injury, a splint may be the best treatment option and is loosely defined as an external device used to immobilize an injury or joint and is most often made out of plaster.  A splint must be differentiated from a cast, to determine the best form of immobilization based on the clinical scenario. Contrary to a splint, a cast is a circumferential application of plaster that rigidly immobilizes a particular joint or fracture. Because of their circumferential restrictive nature, casts are not placed in the acute post-injury setting as they do not accommodate for soft tissue swelling.[1]

Different forms of splints may be fashioned depending on injury location and position of immobilization needed. The goal of splinting is to correct and restore anatomic length, rotation, and angulation of a patient-specific injury. Splints are treatments utilized by a variety of medical personnel as either a temporizing or definitive management strategy for stable fractures.[2][1][3] Proper splint placement is essential since malpositioning can cause undue pain, malreduction, and skin breakdown. Improper splinting not only necessitates replacement, but splint-related soft tissue complications are the second most common iatrogenic cause for referral to plastic surgery. [4] Poor splinting techniques are common, with one study demonstrating inappropriate splinting on 93% of patients.[5] As such, a thorough understanding of the indications, contraindications, and approach to proper splint placement is essential for practitioners that treat patients with acute musculoskeletal injuries.

Anatomy and Physiology

Fashioning a splint takes patient-specific anatomy into account. The splint should be fashioned such that it restores anatomic resting joint position to minimize adverse outcomes. Plaster or fiberglass splints are the mainstays of acute immobilization. Plaster is the preferred malleable material to maintain a position-specific reduction, but it is limited by drying time, user experience, and provider-placed mold. Fiberglass splints are lighter, easier to apply, and more porous, but are more expensive and provide a less-reliable mold. Pre-fabricated splints (such as foam splints or braces) may play a role in chronic injuries necessitating immobilization for structural support or pain control but are less commonly used in the acute fracture setting.

Upper extremity splints crossing the wrist should maintain neutral wrist dorsiflexion, and vascular status should be assessed before and after application to reduce the risk of subsequent complications. In pediatric patients with supracondylar elbow fractures, the arm should never be splinted with the elbow flexed more than 90 degrees, as this increases the risk of Volkman’s ischemic contracture.[6] Lower extremity splints crossing the ankle joint should place the ankle in a resting neutral position without excessive ankle plantarflexion to prevent resultant Achilles flexion contractures. Excess pressure on the soft tissues may decrease the blood flow to the skin surface; this is of particular importance in areas with bony prominences, such as the elbow, knee, and calcaneus, as excess pressure may cause skin irritation and necrosis. Additional layers of protection during the splinting process is of great importance in these regions.

Conversely, excessive splint laxity may permit excessive movement of the injury, and, in cases of fractures, this may result in loss of bony reduction.  If a splint is a definitive therapy, there must be a stable injury pattern. Fractures that are difficult to reduce, excessively shortened, or comminuted are not candidates for definitive splinting, as they usually will need operative intervention by an orthopedic surgeon. However, unstable injuries may still benefit from temporary splinting if the patient is not an immediate candidate for surgery due to concurrent medical issues or if there is an anticipated delay before definitive operative fixation. In these cases, temporary splinting is necessary to avoid further injuries, immobilize the fracture, and promote healing.[7]

Indications

Splints are placed to immobilize musculoskeletal injuries, support healing, and to prevent further damage. The indications for splinting are broad, but commonly include:

• Temporary stabilization of acute fractures, sprains, or strains before further evaluation or definitive operative management

• Immobilization of a suspected occult fracture (such as a scaphoid fracture)

• Severe soft tissue injuries requiring immobilization and protection from further injury

• Definitive management of specific stable fracture patterns

• Peripheral neuropathy requiring extremity protection

• Partial immobilization for minor soft tissue injuries

• Treatment of joint instability, including dislocation

Contraindications

No specific contraindications to splinting exist. However, certain injuries and patient-specific comorbidities require special attention:

• Injuries that violate the skin or open wounds. Antibiotic administration should be considered for these patients depending on the severity of the lesion.[8] These patients also require additional soft tissue care, which may necessitate tissue debridement and skin closure before splint application. 

• Injuries that result in sensory or neurologic deficits. The complications of splint placement such as compartment syndrome, pressure injuries, or malreduction may go unnoticed if the patient has a concurrent nerve injury. These patients should undergo evaluation by a surgeon before splint application as neurologic findings may be a sign of a surgical emergency.

• Injuries to the vasculature require special attention by vascular surgeons, as these may require urgent operative intervention. Furthermore, evaluation of the vasculature is essential both before and after splint application, as the reduction of some fractures may result in acute arterial injury or obstruction if trapped between the fracture fragments.  

• Patients with peripheral vascular disease or neuropathy. Special care should be taken when applying lower extremity splints in these patients since their baseline sensation may be altered. These patients have difficulty detecting pressure sores, skin irritation, and possible vascular compromise.

Equipment

Obtain and organize all equipment before splint application. The necessary equipment for a plaster or fiberglass splint includes:

• Sheet or towel to protect patient clothing

• Stockinette (a soft, loosely knitted stretch fabric) or fabric underpadding

• Undercast padding, which is typically made out of cotton.

• Plaster (8-10 sheets thick) or padded fiberglass. In general, forearm splints require smaller width, and upper arm and leg splints require larger width rolls of material.

• Water bucket filled with cool water.

• Elastic bandage

• Sling for upper extremity injuries

• If fracture reduction is attempted, a C-arm X-ray should be used for the evaluation of the fracture reduction.

Personnel

Splints may be applied by physicians, physician assistants, first-responders, medical assistants, and technicians with the proper training. Although a sole individual may apply a splint, assistance is commonly needed for ease of application. A second provider can gather materials, aid in reduction, and secure the injured limb in position so that the primary provider can adequately place and mold the splint.

Preparation

All materials should be obtained before splint application to avoid the premature setup of the plaster/fiberglass. A careful history and physical exam, including a motor, sensory, and neurovascular exams, should be performed before treatment. Open wounds or soft tissue injuries should be addressed during the preparation phase. Depending on the clinical circumstances., wounds may require antibiotics, wound irrigation, debridement, or tissue closure. The patient’s clothing should be covered with a sheet or pad to prevent plaster or fiberglass from being deposited onto them.  A bucket of water must be obtained to activate the plaster or fiberglass. The splint materials should be measured to fit the desired area, precut, and laid out in the order of use; specifically, a stockinette should be cut to a size that is 8-10cm longer than necessary to cover the splinted area. The plaster or fiberglass should also be measured and cut to an appropriate length, spanning the entire injured area and then stacked 8-10 sheets thick to ensure adequate strength. Additional layers may be necessary for larger joints or larger body habitus, and similarly, fewer may be required in the setting of pediatric cases. Analgesia may be required either by oral or intravenous (IV) routes. Conscious sedation may be needed for pediatric patients.

Technique or Treatment

General steps may be applied when placing a splint

• Ensure adequate analgesia before splint application. This will ensure muscle relaxation and facilitate fracture reduction, if necessary.

• Ensure that any soft-tissue injuries are addressed before splint placement.

• Apply a stockinette circumferentially to the injured area. This should span both proximally and distal to the injured area, protecting the skin from irritation by the plaster or fiberglass.

• Pad bony prominences such as the elbow, knee, or calcaneus with at least 1 cm to 2 cm of soft cast padding. Soft tissue protection is essential to prevent future skin irritation or necrosis. The thickness of this padding will depend on body habitus. 

• Apply 2-3 layers of cast padding (0.25 cm to 0.5 cm) circumferentially to the remaining area of immobilization.

• Reduce any fracture by restoring the bone length, rotation, and alignment. This may require radiographic confirmation before support material application.

• Activate the supportive plaster or fiberglass layers by saturating them in the water bucket. Laminate the sheets by pressing them together before application, as this increases the strength and adhesion between the layers.

• Mold the supportive material around the area of injury. The specific molding approach will depend on the type of injury; however, as a general rule, the splint should be molded to resist any deforming angulation.

• Ensure the supportive material does not circumferentially encase the injured area to accommodate any soft-tissue swelling. If there is circumferential overlap, this should be addressed by cutting the splint once the supportive material has set. 

• Fold the stockinette over the plaster or fiberglass to protect the patient’s skin from its sharp edges.

• Circumferentially apply an elastic bandage around the splint. This aids in the molding of the splint material to the injured area and holds the support material in place until it has hardened. Direct placement on the skin should be avoided and is a commonly observed mistake.[9] 

• Repeat the physical exam to ensure that there is no significant change in the patient’s neurovascular status. Any change in the physical exam should prompt the rapid removal of the splint and reassessment.

• Counsel the patient on proper splint care and follow-up instructions.

Common upper extremity splints include:

• Coaptation splint, sugar tong splint, posterior long arm elbow splint, ulnar gutter splint, radial gutter splint, volar or dorsal short arm splint, thumb spica splint

Common lower extremity splints include:

• Posterior long leg splint, posterior short leg splint, posterior short leg splint with stirrups

These specific splinting approaches are well described elsewhere.[10]

Complications

While splints are commonly used, they are often applied improperly or inadequately.[11] Patients should be given a list of signs and symptoms that necessitate a prompt return to a medical professional. Complications include:

• Loss of fracture reduction

• Skin irritation or breakdown

• Joint stiffness. Every effort should be made to immobilize the fewest number of joints possible.

• Thermal injury – Both plaster and fiberglass support materials exhibit exothermic reactions when activated by water. Avoid skin burns by using room-temperature water when activating the support material and through careful monitoring after splint placement.

• Neurovascular compromise – Acute carpal tunnel syndrome is a rare complication following the reduction of a wrist dislocation. Similarly, the reduction of a supracondylar humerus fracture may inadvertently occlude the brachial artery. Both scenarios are exacerbated through splint placement and require prompt splint removal, followed by a possible operative intervention.

• Compartment syndrome – Excessive compression may occur through splint placement, mainly if a splint is circumferential, becoming a cast. 

Clinical Significance

Splints may be used to effectively immobilize an injury, including a sprain, fracture, or soft tissue injury. In specific scenarios, splints may be used as definitive management to treat these injuries. Educating patients regarding splint care and return precautions aids in a successful outcome.

A splint must be differentiated from a cast, to determine the best form of immobilization based on the clinical scenario. A splint is a non-circumferential application of plaster or fiberglass that is particularly useful in the acute post-injury setting. A splint’s supportive and forgiving structure allows physiologic swelling common to the acute inflammatory phase. In contrast, a cast is a circumferential application of plaster that rigidly immobilizes a particular joint or fracture. Because of the circumferential nature, casts are commonly not placed in the acute post-injury setting.[1]

Splint application is not a completely benign treatment, and improper placement may result in adverse outcomes. One study found that 40% of patients splinted in the emergency department developed soft tissue complications, including skin ulceration in 6% of patients. [5] Proper splint placement avoids unnecessary pain, complications, and excess healthcare costs. Careful monitoring for subsequent compartment syndrome, neurovascular compromise, skin breakdown, or necrosis should be maintained in the early post-injury period. Patients who complain of numbness or tingling in the affected limb, pale skin, numbness or tingling, or increased pain and swelling should be evaluated immediately for potential complications. Patients should be educated on proper splint care, elevating the injured extremity, keeping it clean and dry. Additionally, the patient should be counseled on return precautions, such as an acute increase in pain or any change in motor or sensory functions.

Enhancing Healthcare Team Outcomes

Splints may be applied by medical personnel with a wide range of clinical backgrounds. Regardless of experience, basic knowledge about proper splint application and complications allows teams to work together to care for patients effectively. Following fracture splinting, follow up care should be coordinated for the patient to ensure improving clinical status. Often this coordination occurs between emergency physicians or first responders and primary care physicians or pediatricians for injuries that do not require specialty level care or operative fixation. This is particularly relevant in the case of pediatric forearm fractures, where most patients receive follow-up care with primary care physicians and not orthopedic specialists.[12] In the setting of multi-trauma, fractures with significant displacement, rotation or malalignment, peri-articular fractures, and open injuries, care should be coordinated with an orthopedic surgeon following the initial provider’s evaluation. Additionally, in these patients with an increased risk of adverse events, post-discharge follow-up phone calls should be arranged to ensure the appropriate continuity of care.

Articles and videos have been developed to help educate medical personnel to improve provider splint application. [10][13][14]

Nursing, Allied Health, and Interprofessional Team Interventions

Splints may be applied by appropriately trained physicians, physician assistants, nurses, technicians. A thorough history and physical exam must be obtained before any intervention. Medical professionals may serve as the primary treating clinician or splinting assistant. Regardless of the role assumed, knowledge about the goals of immobilization and proper splinting techniques will improve patient care. Coordination with an orthopedic specialist is necessary for any unstable injuries. 

Non-orthopedic medical professionals frequently treat patients with acute injuries that require splinting. However, few of these professionals are comfortable splinting injuries, and many have not received dedicated education on proper technique. Incorporating an inter-residency and interprofessional approach between orthopedic surgeons, emergency medicine physicians, family practitioners, and advanced practitioners can significantly improve these skills. [10]

Nursing, Allied Health, and Interprofessional Team Monitoring

Following the splint application, the patient should be instructed regarding proper splint care, including keeping the splint clean and dry, elevating the injured extremity to minimize swelling and 

Strict return precautions include getting the splint wet, change in motor function, sensation, or neurovascular status. Non-operative patients managed in a splint require follow-up care in 1 to 2 weeks after the initial splint placement. Further evaluation may include repeat X-rays, splint change, or conversion to a cast. 

Review Questions

• Access free multiple choice questions on this topic.

• Comment on this article.

Figure

side view volar splint. Contributed by Tammy J. Toney-Butler, RN, CEN, TCRN, CPEN-Author Unknown

Figure

completed splint. Contributed by Tammy J. Toney-Butler, RN, CEN, TCRN, CPEN/Author Unknown

Figure

Short Leg Splint Example from two views. Contributed by Anthony J. Silva, CCMA, EMT-B

Figure

Rose’s Splint on the left, Splints, Welch’s Splints on the Right, amputation, Fractures, elbow joint. Contributed by Wikimedia Commons, (Public Domain)

References

1.

Boyd AS, Benjamin HJ, Asplund C. Principles of casting and splinting. Am Fam Physician. 2009 Jan 01;79(1):16-22. [PubMed: 19145960]

2.

Boyd AS, Benjamin HJ, Asplund C. Splints and casts: indications and methods. Am Fam Physician. 2009 Sep 01;80(5):491-9. [PubMed: 19725490]

3.

Leggit JC, McLeod G. MSK injury? Make splinting choices based on the evidence. J Fam Pract. 2018 Nov;67(11):678-683. [PubMed: 30481246]

4.

Lee TG, Chung S, Chung YK. A retrospective review of iatrogenic skin and soft tissue injuries. Arch Plast Surg. 2012 Jul;39(4):412-6. [PMC free article: PMC3408289] [PubMed: 22872847]

5.

Abzug JM, Schwartz BS, Johnson AJ. Assessment of Splints Applied for Pediatric Fractures in an Emergency Department/Urgent Care Environment. J Pediatr Orthop. 2019 Feb;39(2):76-84. [PubMed: 28060178]

6.

Hosseinzadeh P, Hayes CB. Compartment Syndrome in Children. Orthop Clin North Am. 2016 Jul;47(3):579-87. [PubMed: 27241380]

7.

Ryan JR. Fractures and dislocations encountered by the general surgeon: general principles. Surg Clin North Am. 1977 Feb;57(1):197-210. [PubMed: 857333]

8.

Gosselin RA, Roberts I, Gillespie WJ. Antibiotics for preventing infection in open limb fractures. Cochrane Database Syst Rev. 2004;2004(1):CD003764. [PMC free article: PMC8728739] [PubMed: 14974035]

9.

Study: Education, training on proper splint technique needed in EDs, urgent care centers. ED Manag. 2015 Feb;27(2):21-3. [PubMed: 25688416]

10.

Wendling A, Vopat M, Patel O, Wool N, Davis N, Dart B. Enhancing Splinting Confidence through Inter-Residency Education: An Educational Workshop. Kans J Med. 2020;13:29-37. [PMC free article: PMC7053410] [PubMed: 32190184]

11.

Halanski M, Noonan KJ. Cast and splint immobilization: complications. J Am Acad Orthop Surg. 2008 Jan;16(1):30-40. [PubMed: 18180390]

12.

Koelink E, Schuh S, Howard A, Stimec J, Barra L, Boutis K. Primary Care Physician Follow-up of Distal Radius Buckle Fractures. Pediatrics. 2016 Jan;137(1) [PubMed: 26729537]

13.

Fitch MT, Nicks BA, Pariyadath M, McGinnis HD, Manthey DE. Videos in clinical medicine. Basic splinting techniques. N Engl J Med. 2008 Dec 25;359(26):e32. [PubMed: 19109569]

14.

Cheng YT, Liu DR, Wang VJ. Teaching Splinting Techniques Using a Just-in-Time Training Instructional Video. Pediatr Emerg Care. 2017 Mar;33(3):166-170. [PubMed: 25834963]

Disclosure: Alyssa Althoff declares no relevant financial relationships with ineligible companies.

Disclosure: Russell Reeves declares no relevant financial relationships with ineligible companies.

Personal site – Principles of surgical stabilization, splinting

1.3.1.5 Principles of surgical stabilization

There are two fundamentally different mechanisms of fracture fixation: splinting and compression (compression). The differences lie in the mechanism of stabilization and in the degree of stability achieved.

Splinting

Splinting fixation (Fig. 1.11) consists in connecting bone fragments with a (more or less) rigid device or appliance. This device reduces the mobility in the fracture area in proportion to its stiffness. Splinting can be performed in a variety of ways, ranging from external splints (eg, cast fixation) to internal fixation with plates and intramedullary nails. There is also percutaneous splinting: external fixators. The effect of splinting is to reduce (but not eliminate) the mobility of bone fragments. Thus, the pain is reduced and the limb is protected from excessive deformation. Some recommend the use of plates made of materials that have the same stiffness as bone. However, although the mobility of the fragments is inversely proportional to the rigidity of the tire, there is still no reason to use such a plate.

A special type of splinting is support splinting, when a rigid splint is used to maintain the shape of the bone after reduction of a complex fracture or in the presence of a defect. The implant restores a bone segment that cannot bear the load without a splint. The implant, in this case, must be able to take on the full functional load until the bone itself can fulfill this role. In this case, special precautions must be taken to protect the implant from destruction.

Table 1.2 Relative stiffness of bone, plate and nail.

The stiffness of so-called rigid internal fixation implants made of steel can be equal to the stiffness of the bone under axial load, but it is 25 times less in flexion and 20 times less in torsion than bone.

Splint connection

As noted above, the splint must be connected (attached) to the broken bone. The effectiveness of the connection depends, to a large extent, on the stiffness of the softest elements in the ligament: bone/soft tissue/splint. Gypsum, as such, is very cruel due to its large size. However, it provides very limited fracture stabilization due to the fact that the connection between the cast and the bone is not rigid due to the significant amount of soft tissue. Although a cast is an effective conservative treatment (Bobher 1938; Latta et al., 1980; Sarmiento 1984), however, he hardly provides unloading of a stable internal fixation, because leaves the possibility of angular displacement of the fragments and, in addition, increases the internal stress.

In cases where a fracture fixed with a lag screw and plate is subjected to bending force, the screws can move even with a small total deformation. The plaster is thus unable to prevent either screw displacement or plate failure under fatigue conditions, and in such a situation the surgeon has to reduce the external load. The thread breaks already at an angular displacement, which is much less than the angle of mobility allowed by immobilization in plaster.

Non-blocking intramedullary nail fixation is very good in terms of resisting flexion; in relation to the axial load and twisting, it depends on friction (at the same time, in the case of twisting, friction is not only very small, but its effect is minimal). The connection when using external fixators depends mainly on the rigidity of the rods. In this case, the thread area provides much less rigidity than the base of the rod (screw, screw), bending and twisting rigidity varies in direct proportion to the main diameter of the rod body to the fourth power. The main diameter is the diameter along the outer layer of the thread or the diameter of the pin body itself.

Fig. 1.11 Basic techniques of internal fixation.

1: splinting.

A External cast splinting is based on the same basic principles as emergency medical splinting: the splint fixes the bone. Due to its rigidity, it reduces (but does not completely eliminate) the mobility of fracture fragments. The tire, if necessary, takes on part or bears the entire load, especially if there is no contact between the fracture fragments. The connection between the cast and the bone is relatively weak due to soft tissue interposition.

B Plate used as a splint: in theory, a plate can be used to hold fracture fragments apart. The plate then bears the full functional load until a strong union is formed. The connection between the plate and the bone is very strong; fixation with a plate of simple fractures (in terms of achieving reliable fracture healing without damage) is not resistant to resorption of the fracture surface (blocking splint).

C A nail used as a splint: the lug always deforms under load. Therefore, the tire reduces but does not eliminate instability (relative stability). The nail is relatively strong and splinting with intramedullary nails (again in terms of achieving reliable fracture union without disruption) is sufficiently resistant to fracture surface resorption ( sliding bar ).

Splinting add-ons

The plate is known to be flexible and, due to its eccentric position, not strong enough to bear the full load of a functioning limb. Mtiller and “Witzel (1984) and Mast et al. (1988) suggested that minimal internal fixation be supplemented by the application of a temporary external fixator (Fig. 1.12a, b). The large lever of the external fixator provides effective unloading of internal implants until „ the bone will not seize” and thus will not be able to take on the former functions of rigidity and strength.

Unloading bone with implantable splints

The classic splints are a nail and an external fixator. Here, special attention is paid to the plate used as a tire. As we will see later, plate splinting reduces the impact of physiological stress on, for example, an interfragmentary lag screw. The unloading of the bone segment fixed by the plate is one of the most important components of the function of the neutralization and support (support) plates. Most other implants act in a similar way and relieve or protect the fractured bone from excessive physiological stress to ensure smooth fracture healing during early functional healing and to prevent mechanical failure of incompletely healed fractures. In turn, mechanically restored bone, due to its “structural integrity”, protects the implant, for example, from its fatigue fracture.

Fig. 1.12 Supplement to splint

A A multifragmentary fracture was splinted with a low access plate using a minimum number of screws. The operation was not aimed at exact reposition. Fixation only with a plate is not strong enough, therefore, an external fixator is additionally used.

B The resulting callus provides firm support from the opposite cortex. The external fixator can therefore be removed after 6 weeks. (To Baumgirtel, personal communication).

C After the callus is able to perform a supporting function, the external fixator is removed. Thus, the time of percutaneous fixation is reduced to a minimum and internal fixation begins to perform the function of protecting the fracture area.

Sliding and non-slip splints

There are two main principles of splinting: one allows the fragments to slide along the implants, the other prevents it (Fig. 1.13). A conventional, non-blocking intramedullary nail allows bone fragments to slide along the nail because there is very little friction between the nail and the bone. The plate is generally non-slip because the friction resulting from the screwing of the plate is extremely high (each screw causes compression between the underside of the plate and the bone to the extent of 3000 N)11.

The intramedullary nail is an effective way to treat fractures without additional immobilization. A slight displacement in the area of ​​the fracture, allowed by the nail without blocking, can lead to shortening of the ends of the fragments due to resorption (resorption) of their ends. The possibility of sliding along the nail provides (in case of resorption) the adaptation of fracture fragments and their restabilization.

Osteosynthesis with plate in case of a simple fracture without additional stabilization measures (such as, for example, inter-fragment compression ) cannot provide sufficient stability and thus prevent resorption caused by micro-movements between the ends of the fragments. If such shortenings occur, then the high degree of friction between the inner side of the plate and the bone surface does not allow for adaptation. The plate then assumes the entire load applied to the bone and is subject to the risk of “fatigue failure”. Thus, the use of the plate requires the creation of interfragmentary compression by screws and / or axial compression caused by itself, with or without preliminary bending of the plate, so so that part of the load is borne by the bone and thus improved stabilization.As a general rule, a plate alone should not be used to stabilize a fracture in a bone subjected to body weight. , tightening screws).Thus, unload (protect) the fracture and splint it for partial unloading and allowing the restoration of bone contact. If the fracture gap under the plate remains open, then the bone in the fracture area is completely unloaded by the implant.

An important goal of osteosynthesis with a plate is the partial unloading of a broken bone that has been previously fixed with screws. The distribution of loads is thus a prerequisite, and not a primarily undesirable effect of treatment. This fact has often been misunderstood in recent years.

Another fact that needs to be noted here regarding axial load is that the stiffness of the so-called “rigid internal fixation plate” made of steel is equal to that of, for example, the tibia. However, the stiffness of the plate is many times less than that of the bone at bending and twisting. The nail is also “soft” under torsional forces. When twisted, the connection between the non-blocking nail and the bone is generally not rigid. Blocked nails provide a stronger torsional connection because there is initially no movement of the blocking bolts or screws in the nail holes.

If a coefficient of friction (metal-to-bone) of 0.4 is taken into account, and if three screws are implanted in each of the fragments, then a surface subjected to a normal load of 3000 N per screw is capable of withstanding more than 3600 N tangentially applied force (on each side of the fracture) without causing slip.

Fig .1.13 Sliding and non-slip tires .

A Gliding Splint: An intramedullary nail, used without blocking, allows the fragments to close the fracture gap where surface resorption has occurred.

B Non-slip tire: under the conditions described in point a, plastic (especially with round holes) does not slip. In this case, technically incorrect fixation of the plate (incorrect location and function of the lag screws, poor placement of the plate screws) left the fracture gap open. The relative mobility of the fragments (due to incomplete loosening of the implant) resulted in a pronounced deformity (see page 16). There was a slow consolidation. Left – immediately after the operation; right, 8 months after surgery, (from Perren and Boitzy 1978).

Fig. 1.13

Compression

Compression is a very elegant method of fracture stabilization, since effective stabilization is achieved with a minimum amount of implant material. Compression fixation consists in the mutual compression of two surfaces (bone-to-bone or implant-to-bone).

There are two different types of compression depending on the change over time:

Static compression that does NOT change over time. Once applied, static compression remains almost unchanged.

Dynamic compression. The function of the limbs, for example, leads to a periodic change in the load and unloading of the contact surfaces. A wire or plate used as a tie transforms functional tension into compression. The result is a fixation that allows some movement caused by the load.

The effect of compression is twofold:

Compression results in a preload, i. e. the surfaces remain in close contact as long as the applied compression force is greater than the force acting in the opposite direction (e.g. which leads to bending, Fig. 1.14a).

Compression causes friction, that is, the compressed surfaces of the fragments resist displacement (slip) for as long as the friction caused by compression is higher than the applied shear forces (Figure 1.14b, c). The action of local shear forces in a transverse fracture is, as a rule, a consequence of the action of torsion applied along the long axis of the bone. At the same time, the inclined surfaces of the ends of the fragments (for oblique fractures) are subjected to shear forces from the load of the bone along its long axis, for example, when loaded with body weight.

Various methods are used for compression. They differ not only in the type of implant, but also in the mechanism and efficiency of compression.

Fig. 1.14 Basic techniques of internal fixation.

2: Compression.

A Stabilization by compression preload. Preload is effective when the compression stabilizing the mating surfaces exceeds the stretch caused by flexion

(Pergen 1971).

B Compression stabilization with sufficient friction. The compression of the contact surfaces causes friction, which counteracts possible displacement. This mechanism is especially important when stabilizing the contact surfaces of a structure subjected to torsional loads. No displacement occurs.

C Loss of compression stabilization due to insufficient friction. If the created friction is too low and/or the torsion (shear) load in the fracture zone is too high, then the surfaces slide along each other: instability.

Fig. 1.14

Interfragmentary compression with lag screws

Fracture can be compressed by applying a screw inserted perpendicular to the fracture plane (Fig. 1.15). In this case, the thread of the screw is fixed in the opposite cortical layer of the bone. Therefore, when tightening the screw, the far fragment is attracted to the near fragment, on which the screw head presses (Fig. 1.15b). It is extremely important that the fragment on the side of the screw head is pressed only by the head itself. This is achieved either by using a partially threaded screw or by expanding the hole in the fragment on the side of the screw head (sliding hole). In order for the sliding hole to perform its correct function, it is necessary to insert the screw along the axis of the drilled hole (since forces acting perpendicular to the long axis of the screw can shear the threads in the bone and therefore lose the tightening effect).

The compression caused by the lag screw is very effective as it is (among other reasons) relatively strong. Brennwald et al. (1975) and Von Arx (1975) determined that the force applied by an experienced surgeon to the screw fixing the plate is 2000-4000 N. It is important to note that the force caused by the lag screw acts within the fracture surface (Fig. 1.15d), as opposed to plate-induced compression (see below).

Notably, the compressive action of the lag screw must be directed exactly perpendicular to the fracture surface. As shown by Johner et al. (1983), if the direction of compression during oblique osteotomy deviates by only 20% from the perpendicular to the plane of the fracture, then slippage of the fragments occurs.

The “half angle” theory (the screw is best inserted along the bisector of the angle between perpendicular to the fracture plane and perpendicular to the long axis of the bone) is applicable only in the special case of a spiral fracture, in which the surfaces are subjected to perpendicular compression. In this case, the tilt of the screw can be selected according to the perpendicular to the visible plane of the spiral fracture.0005

The assumption that the axial load acts along the long axis of the shaft of the bone in a fracture with a complex load distribution is correct only for short pieces of bone. Therefore, with a complex fracture configuration, it is safest to choose such an inclination of the lag screw, in which it would be perpendicular to the “average” plane of the fracture.

decreases with distance from the axis of the screw insertion.Thus, the implantation of a single lag screw may not provide good stabilization against the torsional forces acting on the fracture surface.

Fig. 1.15 Principles of lag screw technique.

A To determine the best insertion point and inclination of the screws, use a clamp that acts as screws for temporary fixation of the fracture. The clamp is also used to prevent displacement.

B Lag screw replaces clamp; its localization and position (tilt) contribute to the best stabilization.

C The lag screw is best positioned at right angles to the plane of the fracture.

The use of the “bisector rule” is correct only for fixation of an osteotomy with an angle of inclination of less than 40º, according to Johner et al. (1982).

D Photoelastic analysis shows that the compression area is relatively small, which explains why a single lag screw cannot resist rotation.0005

Fixation with the lag screw provides an immobile fixation (“absolute stability”), however often the applied force is much greater, i.e. the applied functional load can lead to displacement. A single episode of overloading the lag screw leads to an irreversible loss of compression. The lag screw is often secured by means of a plate with a so-called neutralization (better: “protective”) function. The combination of a lag screw and a protective plate has been studied by Barraud (1982) and Eisner et al. (1985). Dielil (1976) analyzed the stability and strength of various types of internal fixation of the femur and tibia during early rehabilitation.

to contents read more

tires, photo » Dental portal

Fractures of the bones of the facial part are considered quite rare. According to statistics, fractures of this type make up only about three percent of the total number of fractures of all bones. But their treatment is associated with certain difficulties, since complete immobility, fixation of the jaws is required. Ensuring this is quite difficult. Splinting allows to achieve immobilization.

Contents

• 1 How is splinting for a broken jaw
• 2 How much to walk with splints for a broken jaw?
• 3 How are splints removed after a jaw fracture?
• 4 Nutrition Issues When Wearing Tires

Jaw fractures do not always cause misalignment or distortion of the jaws. Symptoms can be, first of all, severe pain, as well as dizziness, sometimes there is numbness in the area where the fracture occurred (this happens when the nerve endings are torn or ruptured), sometimes the jaw is immobilized, but sometimes pain can occur, only when mouth opening. Therefore, if after a fall or impact you feel any of the above, you need to contact a specialist who will conduct a high-quality diagnosis and select a method of treatment.

Tigerstedt splint with toe loops for fracture of the jaw

As a rule, the initial diagnosis is carried out by palpation. This method allows you to find out if there is a displacement during a fracture or fragments. Further diagnosis requires x-rays. This will help the specialist accurately determine the features and severity of the injury. Jaw injuries are dangerous because when they are received, the cervical spine or the brain can be damaged.

The specialist’s task, if the fracture is confirmed, is to form the integrity of the bone – the fragments of the damaged area must fit snugly. Tires in case of a fracture of the jaw allow them to be fixed. It should be noted that splinting for a fracture of the lower jaw is the main type of treatment. But this method is also effective for the treatment of injuries of the upper jaw.

How a splint works for a broken jaw

The procedure is performed under local anesthesia.

Splints for a fracture of the lower jaw, as well as for a fracture of the upper jaw, can be applied in different ways. There are several methods, each of which is selected depending on the nature of the damage.

1. Single sided. It is used when one of the halves of the jawbone is damaged. A copper wire is fixed on the neck of the teeth.
2. Double sided . It is used when the damage is more serious and it is required to fix the jaw in a fixed position from both sides at once. A rigid wire with rings and hooks is used, which can increase the reliability of fixation.
3. Double jaw fixation, as the name implies, is used in the most severe cases, including when fragments are damaged. Here, the most rigid splinting system is required – a copper wire structure is fixed on healthy teeth or to the alveolar bone, and after that both jaws are connected using rubber rings with hooks.

It is worth knowing that an open fracture is characterized not only by damage to the soft and mucous tissues in the oral cavity, but also by a fracture or dislocation of the tooth root. Splinting of teeth in case of a jaw fracture is very effective, but there are a number of cases when teeth have to be removed.

Removal necessary or recommended:

1. If a wisdom tooth was affected by a fracture.
2. If the damaged tooth is severely loose
3. If the fracture extends between the roots of a multi-rooted tooth
4. If a tooth is damaged that has inflammation (radicular cyst or granuloma)
5. If it is impossible to fix and correctly position fragments of a broken jaw without tooth extraction
6. If the tooth has been severely damaged and cannot be restored
7. If the fracture contributed to the dislocation of the tooth
8. If the tooth is impacted

Method of applying copper wire before installing a splint

But if there is a chance of recovery, then it is worth knowing that splinting of teeth in case of a fracture of the lower jaw is just as common as in case of a fracture of the upper jaw. Shunting of the jaw in case of a fracture is a method that allows you to fix the dentoalveolar row into one “monolith”, eliminating their mobility. When an injury occurs, the teeth are sometimes displaced from the alveolar socket – this disrupts the fit of the bone to the tissue. The use of a fixed tire in such cases is a direct indication. Tires allow you to fix loose teeth and prevent them from moving in different directions.

Fractured jaw bypass

The materials used to make splints are quite varied. Among them are plastic, fiberglass, special rubber, metal. Perhaps every experienced doctor has his own set of favorite materials with which he achieves the best results. At the same time, one should not forget about the individuality of each case. Materials are usually selected taking into account the characteristics of the patient’s injury. So what works for one person may not work for another. These questions should be considered by the attending physician.

How long to walk with splints in case of a broken jaw?

In this question, any patient would like to hear specific dates. But, unfortunately, no specialist can do this, since each case is individual. The time it takes to recover depends on the severity and nature of the injury. But equally important is the quality of care.

Double jaw splinting for a fractured jaw

However, in most cases that are not too difficult, patients wear splints for about three or four weeks. It should be noted that during this time, the jaw muscles that are in a stationary state can atrophy. To avoid difficulties, you need to resort to massage, and after removing the tires, therapeutic exercises may be required.

Meanwhile, if we are talking about serious fractures, in which splinters and displacements occur, then the period of wearing splints can even increase up to a year. And sometimes this period cannot be reduced even with high-quality treatment and careful care.

How are splints removed after a jaw fracture?

The decision to remove splints from the jaws is up to the attending physician. To determine whether the damaged bones have recovered, x-rays must be taken. They allow you to accurately assess the patient’s condition and understand whether he still needs fixing structures.

Condition of the oral cavity before removal of splints from the jaw after a fracture

Removal of splints from the jaw after a fracture is a separate issue that worries patients. The procedure can not cause difficulties for an experienced specialist. Typically, patients want to know if it hurts to remove splints after a jaw fracture. Although people have different pain thresholds, most of those who have undergone this procedure agree that it does not cause significant discomfort.

Difficulties usually arise later. It takes time to get used to the lack of a supporting mechanism. In addition, at first, the muscles are weakened. Particular attention should be paid to nutrition.

Nutrition issues while wearing splints

While wearing splints, food should not contain hard or large pieces. Food is recommended to be taken in a mashed form or in the form of a mushy liquid.

At the same time, the patient must be very attentive to his menu. A broken jaw does not mean you have to switch to baby food. It is important that the menu contains a sufficient amount of calcium, phosphorus, silicon. Do not forget about proteins and vitamins, which to a certain extent contribute to the speedy recovery and restoration of bone tissue.

Meat is a source of protein. It is recommended to boil it, then grind it in a blender, and then dilute it with broth. Chopped fruits and vegetables can be eaten. Of course, cereals, as well as hearty baby food, are suitable for this period.

Nutrition issues are especially difficult to resolve in cases where we are talking about a bilateral fracture. A foreign object in the mouth causes discomfort, besides pressing on the teeth. In this case, eating in such cases is usually done using a catheter, which is inserted into the gap between the wisdom teeth.