What are the key principles of splinting broken bones. How can you provide effective first aid for fractures. What materials are needed for proper splint application. Which splinting techniques are most effective for different types of bone breaks.

Understanding Splints: Purpose and Types

A splint is a crucial supportive device used in emergency situations to immobilize and protect suspected fractures in arms or legs. The primary purposes of splinting include:

• Providing pain relief for the fractured limb
• Supporting and stabilizing the bone ends at the fracture site
• Preventing further damage to soft tissues and reducing the risk of bleeding
• Facilitating safe and comfortable transportation of the injured person

There are two main types of splints:

Rigid Splints

Rigid splints are made from inflexible materials such as wood, plastic boards, broomsticks, books, or even rolled-up newspapers. These are ideal for splinting fractured arms or legs.

Flexible Splints

Flexible splints utilize pliable objects like pillows or folded bed sheets. These are particularly useful for foot, ankle, and joint fractures.

Essential Materials for Effective Splinting

To properly splint a broken bone, you’ll need the following materials:

1. A splint (either rigid or flexible, depending on the injury)
2. A thick bandage to place under the splint for comfort (optional)
3. Rope or similar material to secure the splint to the injured limb

Is it possible to create a splint without these materials? Yes, in emergency situations, you can use the patient’s own body as a splint:

• Secure a fractured arm to the patient’s torso using a dressing
• Tie a broken leg to the uninjured leg with a bandage
• Bind a fractured finger to adjacent fingers using a dressing

General Principles of Splinting: A Step-by-Step Guide

While splinting may initially seem complex, following these general principles can simplify the process:

1. Identify the fracture site accurately
2. Control any bleeding using bandages, but avoid applying pressure directly to the fractured area
3. For open fractures where bone protrudes through the skin, do not attempt to push the bone back in place
4. Immobilize the fractured bone, including the joints above and below the injury site
5. Secure the splint firmly to prevent movement, but check circulation to ensure it’s not too tight
6. Splint the limb in the position you find it, prioritizing the patient’s comfort

Why is it crucial to immobilize the joints above and below a fracture? Each bone end in limbs connects to a joint. Movement of these joints can cause displacement of the fractured bone, potentially leading to further damage.

Splinting Techniques for Different Fracture Locations

The approach to splinting varies depending on the location of the fracture:

Arm Fractures

For lower arm fractures, immobilize the wrist and elbow joints. For upper arm fractures, keep the shoulder and elbow joints motionless.

Leg Fractures

When dealing with lower leg fractures, immobilize the knee and ankle joints. For upper leg fractures, keep the knee and hip joints stationary.

Joint Fractures

Joint fractures are particularly challenging. Immobilize the joint itself, as well as the bones above and below it. For example, an elbow fracture requires immobilization of the shoulder and wrist joints as well.

The Role of Medical Slings and Bandages

A medical sling is a versatile tool in fracture first aid. It’s typically a triangular piece of cloth used to immobilize a fractured arm against a rigid splint, maintaining the elbow at a 90-degree angle. Slings can be used in conjunction with or as an alternative to rigid splints.

How should a sling be applied effectively? Follow these steps:

1. Position the triangular cloth with the point towards the elbow
2. Gently lift the injured arm and place it in the center of the cloth
3. Bring the top corner of the triangle over the shoulder on the injured side
4. Tie the two ends behind the neck, ensuring the arm is well-supported
5. Secure the point of the triangle at the elbow with a safety pin or by tucking it in

When using a sling alone, it’s advisable to add an additional bandage for extra support. This bandage, typically a folded drape about 5-6 inches wide, can be wrapped around the arm and torso to further restrict movement.

Casts vs. Splints: Understanding the Differences

While splints are crucial for immediate first aid, casts play a vital role in long-term fracture treatment. But how do casts differ from splints?

Casts

Casts are custom-made, rigid enclosures that completely surround the injured limb. They provide maximum support and protection during the healing process. Casts are typically applied by medical professionals after the fracture has been properly aligned.

Splints

Splints, or half-casts, offer less support than full casts but have the advantage of being more easily adjusted to accommodate swelling. This makes them ideal for initial treatment, especially when significant swelling is expected.

The choice between a cast and a splint depends on various factors, including the type and location of the fracture, the amount of swelling, and the stage of healing. Your doctor will determine which option is best suited for your specific injury.

Caring for Casts and Splints: Essential Tips

Proper care of casts and splints is crucial for effective healing. Here are some key guidelines:

• Keep the cast or splint dry at all times
• Avoid inserting objects under the cast to scratch itchy skin
• Don’t remove padding from the cast or splint
• Avoid getting dirt or sand inside the cast
• Inspect the skin around the cast edges for signs of irritation
• Elevate the limb to reduce swelling, especially in the first 24-72 hours

How can you safely keep a cast dry during bathing or showering? Use plastic bags or specialized cast covers to protect the cast from water. For added protection, secure the covering with waterproof tape.

When to Seek Medical Attention for Cast or Splint Issues

While casts and splints are designed to support healing, they can sometimes cause complications. It’s important to be aware of warning signs that require immediate medical attention:

• Increased pain, swelling, or numbness in the affected limb
• Burning or stinging sensations under the cast
• Inability to move the fingers or toes of the casted extremity
• Foul odor or drainage coming from inside the cast
• Fever or chills, which could indicate an infection
• Cracks, soft spots, or breaks in the cast material

If you experience any of these symptoms, contact your healthcare provider promptly. Ignoring these signs could lead to serious complications and delay the healing process.

Advanced Splinting Techniques for Specific Injuries

While basic splinting principles apply to most fractures, certain injuries require specialized techniques:

Spinal Injuries

Suspected spinal injuries require extreme caution. The goal is to immobilize the entire spine to prevent further damage. This typically involves using a rigid backboard and cervical collar, applied by trained professionals.

Pelvic Fractures

Pelvic fractures are serious injuries that can cause significant internal bleeding. A specialized pelvic binder or a sheet wrapped tightly around the hips can help stabilize the fracture until medical help arrives.

Facial Fractures

Facial fractures, particularly those involving the jaw, require unique splinting approaches. A barton bandage or a specialized maxillofacial splint may be used to immobilize the jaw while allowing for breathing and potential vomiting.

How do these advanced techniques differ from standard splinting? They often require specialized equipment and training, focusing on immobilizing larger areas of the body or addressing unique anatomical challenges.

The Future of Fracture Care: Innovations in Splinting and Casting

The field of orthopedics is constantly evolving, with new technologies emerging to improve fracture care. Some exciting developments include:

• 3D-printed casts: Custom-designed for each patient, offering better fit and comfort
• Smart casts: Equipped with sensors to monitor healing progress and detect complications
• Bioresorbable splints: Made from materials that gradually dissolve as the bone heals
• Exoskeleton splints: Providing support while allowing for controlled movement

How might these innovations change the way we approach fracture treatment? These advancements could lead to faster healing times, reduced complications, and improved patient comfort during the recovery process.

As research continues, we can expect to see even more sophisticated splinting and casting techniques that optimize the healing process while minimizing discomfort and inconvenience for patients.

Psychological Aspects of Fracture Recovery

While the physical aspects of fracture treatment are crucial, it’s equally important to address the psychological impact of a broken bone. Patients often experience:

• Frustration with limited mobility
• Anxiety about the healing process
• Depression due to prolonged recovery periods
• Fear of re-injury once the cast or splint is removed

How can healthcare providers and caregivers support patients emotionally during fracture recovery? Consider these strategies:

1. Provide clear information about the healing process and expected timeline
2. Encourage participation in physical therapy and rehabilitation exercises
3. Offer resources for coping with temporary lifestyle changes
4. Promote social support and engagement in modified activities
5. Consider referral to mental health professionals if needed

By addressing both the physical and emotional aspects of fracture recovery, patients can achieve better overall outcomes and a smoother return to their normal activities.

Preventing Fractures: Proactive Measures for Bone Health

While accidents happen, many fractures can be prevented through proactive measures. Consider these strategies for maintaining strong, healthy bones:

• Maintain a balanced diet rich in calcium and vitamin D
• Engage in weight-bearing exercises to strengthen bones
• Practice good posture and body mechanics
• Ensure your home is free of trip hazards
• Wear appropriate protective gear during sports and physical activities
• Get regular bone density screenings, especially if you’re at high risk for osteoporosis

How effective are these preventive measures? Studies have shown that a combination of proper nutrition, exercise, and safety precautions can significantly reduce the risk of fractures, particularly in older adults and those with compromised bone health.

Remember, investing in bone health is a lifelong process. By adopting these habits early and maintaining them throughout life, you can significantly reduce your risk of fractures and enjoy better overall skeletal health.

Legal and Ethical Considerations in Fracture First Aid

When providing first aid for fractures, it’s important to be aware of the legal and ethical implications of your actions. Consider the following points:

• Good Samaritan Laws: Many jurisdictions have laws protecting individuals who provide emergency assistance in good faith
• Consent: When possible, obtain verbal consent before providing aid to a conscious adult
• Scope of Practice: Stay within your level of training and expertise
• Documentation: If possible, document your actions and observations
• Handover: Provide clear information to professional medical responders when they arrive

What are the potential consequences of overstepping your boundaries when providing fracture first aid? Attempting procedures beyond your training could lead to further injury to the patient and potential legal liability. Always prioritize the patient’s safety and well-being, and know when to step back and wait for professional medical assistance.

By understanding these legal and ethical considerations, you can provide invaluable assistance to injured individuals while protecting yourself from potential legal issues.

Splinting in Special Populations: Pediatric and Geriatric Considerations

The principles of splinting apply across all age groups, but there are special considerations for pediatric and geriatric patients:

Pediatric Splinting

• Children’s bones are more flexible and may not break completely (greenstick fractures)
• Growth plates near joints are vulnerable and require careful handling
• Splints may need to be smaller or specially designed for children
• Distraction techniques can be helpful when applying splints to young children

Geriatric Splinting

• Older adults may have more fragile bones due to osteoporosis
• Skin is often more delicate and prone to injury from pressure
• Existing medical conditions may complicate fracture management
• Cognitive impairments may affect the patient’s ability to follow instructions or report pain

How do these differences impact the splinting process? For pediatric patients, extra care must be taken to protect growth plates and use age-appropriate splinting materials. With geriatric patients, gentler handling and more frequent skin checks are crucial to prevent complications.

By understanding these unique needs, first responders and healthcare providers can ensure that splinting techniques are adapted appropriately for patients of all ages, promoting better outcomes and reducing the risk of complications.

First Aid – Splint

What is splint? 

A splint is a supportive device used to keep in place any suspected fracture in one’s arm or leg.

Splint is used to:

• Provide pain relief of the fractured limb.
• Support bone ends of the fracture site. Bones ends of the fracture site are very sharp. A splint helps prevent bone protruding through the skin, soft skin and tissue damage, as well as bleeding.
• Facilitate safe and seamless causality transport.

 What is Splint? 

In emergency cases, anything can be used for splinting, yet there are two types of splints:

1. Flexible
2. Rigid 

Rigid Splint: Any rigid object, such as wood or plastic boards, broomstick, book or a rolled-out newspapers, which can be used to splint a fractured arm or leg.

Flexible Splint: Any flexible object, like a pillow or a bed sheet with several folds. This type is used for foot, ankle and joint fractures.

 What are Medical Sling and Bandage?

 A Medical Sling is a piece of cloth used to immobilize the fractured arm to the rigid splint, in 90° of elbow flexion. The sling usually takes the shape of a big triangle. It can be used along with or instead of a rigid splint. If used alone, the sling should be supported with an additional bandage which is actually a folded drape of 5-6 inches width.

General Principles of Splinting: 

Several ways are adopted for splinting, which may seem highly complicated – at first sight – yet they are very simple. Here are some general principles to be applied when splinting as follows:

• Identify the fracture site.
• Stop the bleeding using bandages, but avoid pressing on the fractured painful and deformed site.
• In case of bone fractures where bone ends protrude through the skin, do not push these ends back in place as this will cause inflammation and acute bleeding.
• Keep the fractured bone (including the joints above and below the fracture site) motionless as indicated hereunder:
• If the lower-arm is fractured, keep the wrist and elbow joints motionless.
• If the upper-arm is fractured, keep the shoulder and elbow joints motionless.
• If the lower-leg is fractured, keep the knee and ankle joints motionless.
• If the upper-leg is fractured, keep the knee and femoral joints motionless.
• Splint should be tied firmly to immobilize the fractured limb, then check for blood circulation to ensure the splinting is not too tight. Correct splinting provides pain relief.
• If the fractured limb is bent with a sharp bone end protruding through the skin, keep it motionless. Splint a limb as you find it to make it as comfortable to the patient as you possible.
• If an ambulance is called and is on its way, do not splint the fractured limb and wait for the ambulance team to use their specialized medical splints.

Why keep upper and lower joints motionless?

Each bone end in limbs is connected to a joint. Moving that joint dislocates the fractured bone. So, joints should remain motionless to immobilize fractured bones.

 What if the joint itself is broken?

This is the most difficult fracture to handle. Yet, follow the same instructions of applying a splint. Make sure to maintain joints, upper and lower bones as well as the fracture site motionless. For example, the elbow joint connects both upper- and lower-arms. If broken, the joint and bones should be immobilized. Hence, both shoulder and wrist joints should remain motionless. 

In most cases, joint fractures are very painful. In this case, never try to relocate the joint least you should damage the nerves and blood vessels around the joint, let alone the acute pain resulting.

You should have an overactive imagination when dealing with such injury. You can splint the joint as you find it.

What Materials are Needed for Splinting?

You will need:

• A splint (rigid or flexible).
• A thick bandage to apply under the splint for maximum comfort. (Optional).
• Robe – or the like – to wrap the splint to the fractured limb.

 What if these materials are not available?

No worries. You can use the patient’s body as a splint as follows:

• You can tie the fractured arm to the patient’s body using a dressing.
• You can tie the fractured leg to the patient’s other leg using a dressing.
• You can tie the fractured finger to the patient’s other fingers using a dressing. 

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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.

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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.

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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

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.

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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.