Should this injury be splinted in the ED?

No! As important as it is to know when and how we should reduce injuries for splinting, it is equally crucial to know when not to reduce and splint immediately. In this case, an open fracture should not be reduced as it will need surgical wash out and fixation. [1,2-3]

• Pearl: At institutions with full or busy ORs where there is an expected delay to definitive care, the fracture can be splinted for patient comfort. The same practice would also be appropriate in patients requiring transfer to other institutions for orthopedic evaluation. Splinting for comfort is an institutionally dependent practice, but no matter where you are the injury should not be significantly manipulated for splinting or reduced manually. 

What are the contraindications to immediate splinting in the ER?

The 4 major considerations prior to immediate splinting are listed below:

• Open Fractures: these require antibiotic administration, debridement and surgical fixation (with the exception of splinting for comfort as noted above). 

• Wounds that result in neurovascular compromise: these wounds may be worsened by immediate splint application and are at high risk for compartment syndrome, pressure injuries or malreduction. They should be immediately evaluated by a surgeon.

• Patients with significant diabetic neuropathy: Splinting these individuals is high risk for pressure injury as they may not be able to feel the development of ulcers or other wounds. 

• Concern for infection: limbs with infection concern need continuous re-evaluation which is difficult after splint application. In addition, the splint itself provides an ideal environment for bacteria to grow. [1,2-3]

What are the indications for a splint?

Splints aren’t just for fractures. They are designed for immobilizing musculoskeletal injuries in order to promote healing and prevent further damage. For that reason, splints can also be helpful in the following conditions:

• Definitive fracture management

• Stabilization of fractures that will require alternative definitive management

• Severe soft tissue injury requiring immobilization and further protection

• Reduced Joint dislocations

• Tendon lacerations or rupture

• Peripheral neuropathy requiring extremity protection [1,3-4]

• Superficial lacerations that cross joints or high tension areas

In which instances is a removable brace appropriate?

Removable braces have the advantage of easier application, ability to re-evaluate as needed, and prevention of the pressure ulcers that can be associated with splinting or casting. Studies have shown equivalent or better functional outcomes in uncomplicated ankle fractures, ankle sprains, and wrist buckle fractures in the pediatric population [5-7]. In addition, in the adult population, the following conditions can be treated by removable splint:

• Extensor Mechanism Injuries of the Knee: Knee Immobilizer

• Ankle Sprain: Functional ankle brace (AirCast)

• De Quervain Tenosynovitis, Scaphoid Fracture: Thumb Spica Splint

• Carpal Tunnel: Wrist Splint [4]

What layers should a splint have?

Every splint should have 3 layers:

• Deep layer: padding, optional stockinette

• Middle layer: splint material, most commonly fiberglass or plaster

• Superficial layer: compressive dressing, most commonly ACE or Kerlix [8,9]

What are the major differences between plaster and fiberglass splints?

The use of plaster vs fiberglass is based on provider preference and institutional availability as both have demonstrated efficacy in splint application. 

Fiberglass has a higher yield point and ultimate load when compared to plaster. It is also faster to cure. In the instance where you are aiming for the strongest splint, fiberglass may be preferable. However, plaster demonstrates an initial stiffness which is superior to fiberglass and allows for more customizable molding. [10]

• Pearl: The biomechanical properties of the splint material is significantly affected by the heat of the water that activates and hardens the splint. A higher temperature of water will cause it to harden more quickly, but is associated with a higher risk of serious burn. Reuse of the dipping water will also speed up the hardening process (residual splint material accelerates activation and hardening). Use cool water for fiberglass and lukewarm water for plaster. [8-10]

What should be done after every splint application?

Before and after every splint application the limb should be checked for neurovascular injury. This is accomplished by checking all distal pulses in the affected extremity. If pulses cannot be accessed after placement of the splint, capillary refill should suffice. In addition, the motor and sensory function of distal limbs should be evaluated. [8-9]