Common Splinting Techniques.ppt

Casting

1. Common Splinting
Techniques
Jenniffer L. LaPointe, MD
Maj, USAF, MC
and
Charles W. Webb, DO
MAJ, MC, USA

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

3. RVU “density”
Example: Healthy 5 year old female comes in after
FOOSH injury with nondisplaced torus fx of distal
radius on x-ray, normal exam except for
tenderness over distal radius
•On initial visit: 99213 visit (0.67 RVUs) with CPT
29125, application of short arm splint (0.59 RVUs) with
total RVUs on initial visit: 1.26 RVUs
•THEN patient f/u done 3-4 days later after swelling has
decreased and 99213 coded (0.67 RVUs) and CPT
25500, closed treatment of radial shaft fracture without
manipulation (1.69 RVUs) with total of : 2.36 RVUs
•Follow up in 3 weeks with removal of cast, 99213 (0.67
RVUs)
•Total of 4.29 RVUs for treatment and orthopedic referral
avoided

4. Pre and Post Splint Checks
F –Function
A –Arterial Pulse
C –Capillary Refill
T –Temperature (Skin)
S -Sensation

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

6. When do I need an orthopedist?
Indications for orthopedic referral
•Scaphoid Fractures:any displacement or
angulation, non-union or avascular necrosis
develops after conservative treatment, or
scapholunate dissociation (>3mm distance)
•Proximal Thumb Fractures:any intraarticular
fracture, comminution, any fracture where
adequate closed reduction cannot be maintained
•Ulnar Collateral Ligament Injuries:avulsion
fracture with more than 2 mm displacement,
fractures with more than 20% articular surface
involvement, complete rupture of UCL (tested at 30
degrees flexion of MCP afterradiographs are
obtained)

7. Volar Splint –3” or 4”
Indications
•Wrist Sprains
•Carpal Tunnel Syndrome/Night Splints
•Lacerations
•Simple/nondisplaced radius or ulna fractures
Key Points
•palmar crease to 3 fingerbreadths from
antecubital fossa
•1” fold @ angle of palmar crease

8. Teardrop Splint –4”-5”
Indications
•2
nd
& 3
rd
Metacarpal Fractures
•Flexor Tendon Repairs or Extensor Tendon
•Crushing Injuries
•Lacerations
Key Points
•Tip of 3
rd
finger to 3 fingerbreadths from
antecubital fossa
•Cut 2 ½” hole for thumb & tape edges
•Flex metacarpals 45°(70-90°if distal fracture)
and wrist 20-30°extension

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

10. Reverse Sugar Tong –3”-4”
Indications
•Colles’ Fracture
•Forearm Fractures
Key Points
•Measure from behind the elbow up both sides
of the arm to the tip of the fingers
•Cut at mid-point leaving 1/2” and slide over
the hand
•Overlap the ends at the elbow, wrap from the
hand down

11. Figure 8 Splint
Indications
•Mid-shaft clavicular fractures (Proximal/distal
clavicular fractures often treated with
sling/swath +/-operative treatment)
Key Points
•Measure so “position of attention” attained
•Advantage of leaving elbow and hand free BUT
requires assistance to put on
•Counsel patient bony deformity possible
•Orthopedic referral rarely indicated for mid-
clavicular fractures

12. Posterior Ankle –4” -5”
Indications
•Distal Tib / Fib Fractures
•Ankle Sprains
•Achilles Tendon Tears
•Metatarsal Fractures
Key Points
•2” below popliteal to 2” beyond toes
•Fold 1” under toes
•Wrap from the toes up
•Figure 8 with tape to hold in position

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

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

15. Avoiding pitfalls
Worst outcomes in fracture management:
•Fractures requiring reduction
•Intraarticular fractures
•Scaphoid fractures
Reference resources:
•Up To Date ®
•Fracture Management For Primary Care, by
Eiff, Hatch, and Calmbach
•Rockwood and Green’s